| BackgroundAntimicrobial resistance(AMR)is one of the greatest threats to public health this century.The primary cause of AMR is antibiotic overuse and misuse.Economic incentives and lack of professional knowledge were considered as major contributors to Chinese supply-side antibiotic irrational use.Policies and interventions can be seen to tackle down the crisis from the supply-side by the Chinese ministry of health.However,growing evidence has shown that the demand-side should be taken into consideration for their irrational antibiotic use behaviors including asking for antibiotics from doctors during the consultation,self-medication with antibiotics,take antibiotics for prophylaxis,purchase antibiotics without prescription,keep antibiotics at home,etc.Although the supply-side plays an important role in China antibiotic abuse situation,the demand-side is equally essential,especially with the limited improvement after the introduces of a series of policies to rectify the overuse of antibiotics by doctors.Campaigns in both developing and developed countries targeting or including demand-side have proved effective in improving population AMR related knowledge and reducing antibiotic misuse behaviors.Although the Chinese government has carried out interventions by focusing on the supply-side,there is no intervention targeting the demand-side.AimsThe aim of the cross-sectional study was:1)to explore knowledge and antibiotic use behavior of university students from across China;to determine the association between the knowledge and healthcare-seeking behaviors in relation to antibiotic use;and to examine the contributions of these behaviors to the overall use of antibiotics.2)Based on the cross-sectional survey,we used social media as a channel,crowdsourcing as the method,and public engagement as a motivator to conduct a national campaign targeted on empowering university students to change their awareness,knowledge,and behavior concerning AMR.Methods1.The cross-sectional surveyGeographically,China is divided into six regions.In each region,one province was purposely selected.In each province,a high-ranking multidisciplinary university was selected.A cluster random sampling method was adopted.The aim was to achieve a sample size per university of ca.1800 students.A total of 11,192 respondents completed the questionnaire.The survey was conducted using an online electronic questionnaire tool called Wen Juan Xing.University students’ antibiotic related knowledge(AMR awareness,general knowledge,and medicine identification)and behavior(health-seeking behavior,ask for antibiotics,self-medication with antibiotics,take antibiotics for prophylaxis,keep antibiotics at home and purchase antibiotics without a prescription)were investigated.For data analysis,univariate analysis was used to select the appropriate independent variables which were included in the logistic or linear regressions afterward.2.CampaignThe target population was university students.One to three universities were selected as intervention universities in each province all-over China.The seven-month campaign started on April 1,2016,finished on October 30,2016,and covered an estimated 1.5 million university students across 50 universities in every province of China.The campaign was composed of three key elements including crowdsourcing,social media,and public engagement.Crowdsourcing refers to the process of obtaining needed services,ideas,or content by soliciting contributions from a large group of people and has been championed by the National Institutes of Health in the United States as an effective tool to seek new ideas in health research.The whole process of the campaign is a crowdsourcing contest including five stages:call for artwork,create artwork,expert panel appraisal,online voting,finalist recognition event.The campaign is not only a crowdsourcing process for developing AMR health education artwork but has also created a dynamic space for health education that is both two-dimensional(on-and off-line)and multi-directional(among traditional health educators,participating students,peer,and the public)in disseminating AMR and antibiotics-related knowledge.Public engagement was used as a trigger to arouse the interest of university students and a driver to expand campaign coverage.New media was the main communication channel in the whole process.The intervention design was a campaign,which is a real-world-setting intervention method.The campaign was evaluated using the RE-AIM Framework(reach,efficacy,adoption,implementation,and maintenance),which assessed the potential public health impact of an intervention and concerned with issues related in real-world settings.Two cross-sectional surveys were used to evaluate the campaign effect which has been used in the United States and Hong Kong in assessing campaign effects.The two-cross-sectional surveys were from the same population with a method of cluster random sampling method.The sampling process including two steps:the first step was to select one province in each of the six regions and randomly select one target comprehensive university in that province and a medical university if the comprehensive university does not have a medical school.The second step was to select students in each of the universities.Classes were randomly selected according to the class timetable before the survey.All university students attending these classes were included.A cluster random sampling method was adopted and the aim was to achieve a sample size per university of ca.1200.Twenty-five percent of medical students were guaranteed in consideration of medical students accounted for a high percentage of participation in the campaign.After-intervention survey was conducted the same as before-intervention.A total number of 15,333 students among which 7,865 students before-intervention and 7,468 students after-intervention completed the questionnaire.The campaign evaluation compared baseline(7,865)and after-intervention(7,468),directly covered(855)and non-directly(6,613)covered,directly covered(855)and baseline(7,865)groups.Logistic regressions were adopted to control social demographic characteristics and evaluate the knowledge,including AMR awareness,general antibiotic use related knowledge,antibiotics identification,and the behavior of self-treatment with antibiotics changes by the campaign.Although same universities were sampled to evaluate the campaign effect,the data is not panel data for students were different in each of the sampling processes.To prove the real effect of the campaign,495 university students were identified to took part in the two cross-sectional surveys and were separated into the intervention group(184)and the control(311)group.This study is registered with ClinicalTrials.gov,number ChiCTR-IOh-16009480.ResultsCross-sectional study1)The AMR awareness was high among university students.However,general knowledge(i.e.,37.8%of university students thought that antibiotics are effective for vials;41.0%believed that antibiotics could speed up recovery from flu.)and antibiotic identification(only 45.2%could identify quinolones;25.6%could recognize sulfa.)were low.2)The massive misuse of antibiotics for self-limiting illnesses by well-educated young adults is a serious concern.In the past month,29.6%university students self-medicated with antibiotics.Sixty-six percent of the students who reported ill were prescribed antibiotics,and 22.7%of these students asked for and received antibiotics.In the past year,23.0%of students had used antibiotics for prophylaxis,60.5%stopped taking antibiotics as soon as they felt better and 63.1%kept a personal stock of antibiotics.3)AMR awareness was not related to antibiotic use behaviors,and higher general knowledge was significantly related with rational antibiotic use behaviors(p<0.001).Antibiotic identification worked as a moderator between antibiotic knowledge and behaviors(p<0.01),put it another way students with higher antibiotic identification and higher general knowledge scores were more likely to use antibiotics properly while students with higher antibiotic identification and lower antibiotic general knowledge scores were more likely to use antibiotics inappropriately.4)Keeping antibiotics at home behavior promotes self-medication with antibiotics(aOR=5.01,95%CI 3.53,7.10,p<0.001),and take antibiotics for prophylaxis(aOR=2.60,95%CI 2.34,2.90,p<0.001)among Chinese university students.5)We estimate that in the past month,demand-side contributes more than half of antibiotic use.Campaign1)Reach:One to three high-level universities were covered in each province in China.In total fifty universities were covered by the campaign.However,a total of 356 teams with multi-disciplinary backgrounds from 71 universities participated in this crowdsourcing artwork contest.The spill-out effect in school level was 42.0%.Over 50,000 people participated in the online voting.At the event stage,the campaign was reported by most mass media outlets in China,including China News,Youth Times,Xinhua News,People’s Daily,Sina,Netease,Sohu,etc.Among 7,468 students who completed the survey after the campaign,855(11·4%)participants reported exposure to at least one activity of the campaign.An estimated 169 thousand university students were covered by the campaign.Students who were female(aOR=1.21,95%CI 1.04,1.41,p<0.05),older(OR=1.24,95%CI 1.18,1.29,p<0.001),and those with a medical major(aOR=3.04,95%CI 2.61,3.55,p<0.001)were more likely to be covered by the campaign.2)Effectiveness:Students who had covered by the campaign had a higher AMR awareness(aOR=1.47,95%CI 1.25,1.72,p<0.001),a higher antibiotic use knowledge(aOR=1.88,95%CI 1.58,2.23,p<0.001),and a higher antibiotic identification knowledge(aOR=1.63,95%CI 1.39,1.92,p<0.001)than their baseline counterparts.The students covered by the campaign were 0.32(95%CI 0.17,0.60,p<0.001)times less likely to self-treat with antibiotics compared to the baseline.3)Adoption:The health education artwork created by crowdsourcing to university students have been used by World Health Organization during the Antibiotics Awareness Week in China in November 2016,and United Kingdom Embassy on their Embassy Open Day in September 2017.All the artwork can be downloaded for free from our website and is in use by hospitals,primary health care facilities,CDCs,and universities.4)Implementation:On the individual level,11.4%of university students reported covered by the campaign,the participation rate is slightly higher than the same kind of campaigns in the United States.More than half of the students covered by the campaign reported influences on the people around them(i.e.,64.2%reported talking more about smart antibiotic use with classmates,67.7%reported greater discouragement of others engaging in SMA than before).On the organizational level,the campaign coverage varied from 8.1%to 23.6%in the sampled universities across six regions.Zhejiang and Jilin ranked highest,whereas Gansu and Hubei ranked lowest.This was due to the different implantation efforts made by volunteers and the difference in social media coverages.5)Maintenance:From the effectiveness perspective,the post-intervention survey was conducted six months following the conclusion of the campaign to measure the lasting effects of the intervention.We were not interested in temporary changes to knowledge and behavior among participants but the maintenance of such changes.From a sustainability perspective,this campaign model is a relatively easy way to attract future funders.Conclusion and Policy ImplementationsAs the opinion leader of the society,Chinese university students had high AMR awareness,but lack of antibiotic use related general knowledge and antibiotic identification knowledge.The massive misuse of antibiotics such as self-medication with antibiotics,ask for antibiotics during consultation with doctors,take antibiotics for prophylaxis,and keep antibiotics at home behaviors were common.Students’ awareness level did not influence their behavior;however,higher knowledge was related to rational antibiotic use behavior.Antibiotic identification works as a moderator between general knowledge and antibiotic use behaviors.Keeping antibiotics at home behavior promotes self-medication with antibiotics and take antibiotics for prophylaxis.Given the situation of university students with self-limiting diseases,demand-side contributes more to the irrational antibiotics use than their supply-side counterparts.The crowdsourcing campaign based on social media and public engagement is an effective way to improve university antibiotic knowledge and behavior and is a sustainable and potential replication campaign model.Policy implementation:1)Future antibiotic policy and restrictions should strengthen the health education and interventions toward the demand-side.Given the situation of university students with self-limiting diseases,demand-side contributes more to the irrational antibiotics use than their supply-side counterparts.2)The health education should focus on detailed antibiotic use knowledge and antibiotic identification other than the potential risks of AMR.Because the overwhelming majority of university students had high AMR awareness,however,awareness does not influence behaviors.3)Future health education should focus on what is antibiotics,the difference between antibiotics and anti-inflammatory drugs,and which disease does not need antibiotics other than "use antibiotics properly." 4)The high consultation rate among university students should be improved to lower the total antibiotic consumption.5)Keeping antibiotics at home behavior is a significant risk factor,intervention should be started to eliminate the source of leftover antibiotics.The following policies could be taken into consideration:strengthen the supervision of antibiotics over the counter selling;improve the antibiotic dispensing system from packaged to exact number of tablets;recycling the current home stored antibiotics.6)The crowdsourcing campaign based on crowdsourcing,social media,and public engagement is an effective way of improving university students’ antibiotic knowledge and behavior and could be conducted among young people like university students and children parents in the future. |
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