Antimicrobial Stewardship

Antimicrobial drugs include antibiotics, antivirals and antifungals which are used to kill microorganisms such as bacteria and viruses. The availability of effective antimicrobial drugs are estimated to add 20 years to life expectancy. The emergence of antimicrobial resistance (AMR) therefore poses a serious threat to public health. AMR is the ability of microorganisms to continue to multiply uninhibitedly in the presence of antimicrobial drugs, making conventional treatment ineffective. AMR poses a growing threat to public health, as infections from resistant strains of microbials become increasingly difficult and expensive to treat, resulting in prolonged illness and greater risk of death. The over use and inappropriate use of antimicrobials contribute to the acceleration, emergence and spread of AMR. Strategies that encourage antimicrobials to be used more responsibly and less often are therefore needed to safeguard human health. This includes awareness campaigns targeting the public to raise the profile of the issue and induce societal and cultural change.

RAND Europe was commissioned by NICE Centre for Public Health to conduct a systematic review of the effectiveness and cost-effectiveness of educational interventions aimed at changing risk-related behaviours relating to the use of antimicrobials. This evidence will be used to help inform the development of a guideline aimed at delaying antimicrobial resistance.

This review considered educational interventions targeting individuals, communities or the general public delivered via any number of modes (e.g. classroom education, leaflets, campaigns). Specifically, this review aimed to answer the following research questions:

1. Which educational interventions are effective and cost-effective in changing the public's behaviour to ensure they only ask for antimicrobials when appropriate and use them correctly?
2. Which educational interventions are effective and cost-effective in changing the public's behaviour to prevent infection and reduce the spread of antimicrobial resistance?

This review did not include interventions targeting physicians or other prescribers, as this is the focus of another NICE review conducted in parallel to this one (Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use: http://www.nice.org.uk/guidance/indevelopment/gid-antimicrobialstewardship).

The review was conducted following guidance presented in "Developing NICE guidelines: the manual". A range of relevant databases were searched for data from 2001 onwards. Given that interventions, settings, and population groups differed in the included studies, meta-analyses were not conducted, and the results were summarised narratively in texts and tables.

Overall, 60 studies met the inclusion criteria; 29 of these related to research question 1, and 36 related to research question 2 (5 studies were applicable to both research questions). The results for research question 2 were subdivided into studies related to infection and/or hand hygiene (22 studies) and food safety and hygiene (16 studies). Some studies reported on multiple relevant outcomes and are reported in each relevant section. Twelve studies were rated as moderate quality (+), and the remaining 48 studies were rated as poor quality (-), based on a methodology checklist published by NICE for public health guidance.

The key findings from these studies are briefly summarised below in "Evidence Statements," which are statements that provide a high level overview of the key features of the evidence, including the number of studies, the quality of evidence, and the direction of the estimated effect followed by a brief summary of each of the supporting studies. Studies have been grouped into Evidence Statements by setting and intervention.

Research Question 1: Antibiotic Knowledge and Behaviour

Pharmacist-Led Interventions Targeting Patients or Carers of Patients

Evidence Statement 1.1: Pharmacist-Led Verbal Education, Supplemented with an Information Leaflet

There is weak evidence from one non-randomised controlled trial (non-RCT) (-)¹, one randomised controlled trial (RCT) (-)² and one pre-post study (-)³ indicating that verbal education on antibiotic adherence from a pharmacist, or the combination of written and verbal education on antimicrobial (AM) use and antimicrobial resistance (AMR) delivered by pharmacists, can improve patients' adherence to treatment and knowledge of AM use, but that written and verbal education did not increase awareness of AMR. However, baseline awareness was high, potentially leaving less room for knowledge gain.

One non-RCT¹ (-) (Spain; n=138) found that individualised verbal education about treatment characteristics, duration, dosage regime and how to use the antibiotic delivered by a pharmacist to patients and/or carers before collecting an antibiotic prescription, lead to increased adherence (aOR 2.23 [95%CI: 1.01 to 4.93] p=0.047).

One RCT² (-) (Australia; n=34) found that the provision of a patient education leaflet plus verbal education from a pharmacist led to improved knowledge of antibiotics (the mean difference in "antibiotic knowledge" score increased by 33.3% (±40.8), from 60.0% (±43.9) to 86.6% (17.2) (p=0.008). Conversely, in the control group (who received a "Consumer Medicines Information" leaflet only), there was a non-significant decrease in knowledge of antibiotics; the mean difference in "antibiotic knowledge" score decreased from 83.3% (±23.6) to 80.0% (±35.8) (p=non-significant (ns)). No statistical comparisons were made between the control and intervention groups.

One pre-post study³ (-) (USA; n=130) reported that pharmacist-led verbal education and a patient educational leaflet and handout significantly improved patients' overall understanding of AMR, from 56.5% at baseline to 78.3% at follow up (p=0.026). However, the change-from-baseline for all three individual component questions/statements was non-significant, potentially because baseline knowledge of the participants was already high. The results also indicated some improvements in patients' understanding of the appropriate use of antibiotics. There was a significant increase in the number of patients who correctly reported that antibiotics should not be used to treat viral infections for two out of the four conditions surveyed: cold, from 58.7% to 80.4% (p=0.02), and flu with body aches, from 34.8% to 60.9% (p=0.02).

Applicability:

While none of the studies were conducted in the UK, the evidence is directly applicable to people in the UK as there are no obvious differences in the population, context or setting of the studies compared with the UK context.

[1] Muñoz et al. 2013 (-)

[2] Northey et al. 2010 (-)

[3] Rodis et al. 2004 (-)

Interventions Based in General Practice and/or Led by a GP Targeting Patients or Parents of Paediatric Patients

Evidence Statement 1.2: Video- and Information Leaflet-Based Interventions in General Practice and/or Led by a GP Targeting Parents of Paediatric Patients

There is weak evidence from two RCTs (+)¹ (-)² and one non-RCT (-)³ that the combination of an educational video on antimicrobial use and antimicrobial resistance, supplemented by an information leaflet delivered within a primary care setting, can improve parents' knowledge of appropriate antimicrobial use and expectations of antimicrobials for their child, but that it was not effective in improving awareness of AMR.

One RCT¹ (+) (USA; n=206) found that a 20-minute video programme, supplemented by an information leaflet, both of which aimed to educate parents on the problem of bacterial resistance to antibiotics and their appropriate use to prevent the development of resistance, did not have an impact on knowledge scores or any of the five statements related to beliefs, but did have a significant impact on one of the five behaviour statements: there was a reduction in saving antibiotics for later use when compared with the control group, 3.82 vs 3.62 (p=0.02).

One RCT² (-) (USA; n=499) conducted in a paediatrician's office reported that an information leaflet ("Your Child and Antibiotics") and a video presented by a GP on judicious use of antibiotics was effective in increasing parents' knowledge of when to use antibiotics for all five statements related to appropriate use of antibiotics for specific conditions in children compared with control, but for only one out of the five more general statements related to increasing awareness of AMR.

One non-RCT³ (-) (USA; n=771) conducted in a GP's office found that provision of an information leaflet ("Your Child and Antibiotics") and a video in waiting rooms significantly improved knowledge of when to take antibiotics in those who reported seeing the video vs those who reported not seeing the video at 36 weeks post-intervention: 7.1% vs 29.2% thought that antibiotics should be used to treat a child with fever or a cold (p0.001), and 13.8% vs 44.3% wanted/expected the doctor to prescribe antibiotics for their child (p<0.001).

Applicability:

While none of the studies were conducted in the UK, the evidence is directly applicable to people in the UK, despite differences in the broader healthcare context in the USA, as there are no obvious differences in the population, context or setting of the study compared with the UK context.

[1] Bauchner et al. 2001 (+)

[2] Taylor et al. 2003 (-)

[3] Wheeler et al. 2001 (-)

Evidence Statement 1.3: Communication and/or Information Leaflet-Based Interventions in General Practice Targeting Parents of Paediatric Patients

There is inconsistent evidence from one RCT(-)¹ and one cluster-RCT (+)² on the effectiveness of educational interventions that aim to improve patient doctor dialogue during a GP consultation, supplemented by an information leaflet, on parents expectation of antibiotic treatment or "intention to consult", but there was significant reduction in antibiotic consumption.

One RCT (-)¹ (USA; n=80) found that an intervention to enhance communication between parents and their child's physician (involving role play) and/or an information leaflet ("Your Child and Antibiotics"), plus a fact sheet about antibiotics and AMR, did not significantly change parents' expectations of antibiotic treatment for their child compared with the control group, who were given information on child nutrition. We note that the results were not clearly presented and that therefore no clear data can be presented here.

One cluster-RCT² (+) (England and Wales; n=558 children) found that online training for GPs in combination with a booklet, designed to be used as a consultation aid (to increase doctor/patient communication) and a take home resource for parents, led to significant reductions in antibiotic consumption (22.4% in intervention vs. 43% in control; aOR [95% CI 0.18 to 0.66]) and parents' intention "to consult if their child had a similar illness" (55.3% in intervention vs. 76.4% in control; aOR 0.34 [95%CI 0.20 to 0.57]).

Applicability:

While one of the studies was not conducted in the UK, the evidence is directly applicable to people in the UK, despite differences in the broader healthcare context in the USA, as there are no obvious differences in the population, context or setting of the study compared with the UK context.

[1] Alder et al. 2005 (-)

[2] Francis et al. 2009 (+)

Evidence Statement 1.4: Cold Pack and Information Leaflet-Based Intervention in General Practice Led by a GP Targeting Adult Patients

There is weak evidence from one non-RCT (-)¹ (USA; n=299 analysed) that an information leaflet ("Antibiotics – Did You Know?") distributed in a primary care setting to all participating adult patients, significantly decreased the patients' perceived need for antibiotics at post-test follow up (p<0.001 [pre vs. post for all participants]) and increased their knowledge of appropriate antibiotic use (i.e. for what illnesses one should take antibiotics) (p<0.034 [pre-vs. post for all participants]). A sub-sample of patients were allocated a cold pack which contained products designed to provide symptomatic relief, and sub-group analysis revealed that an increase in appropriate antibiotic use knowledge was significantly larger for the education group (p<0.002), but not for those who received both education and a "cold pack" kit.

Applicability:

While the study was not conducted in the UK, the evidence is directly applicable to people in the UK as there are no obvious differences in the population, context or setting of the study compared with the UK context.

[1] Alden et al. 2010 (-)

Evidence Statement 1.5: Information Leaflet (With or Without Delayed Prescription) Targeting Patients

There is inconsistent evidence from one RCT (-)¹ and one nested-RCT (+)² on the effectiveness of information leaflets within a primary care setting to reduce antibiotic use in patients with lower respiratory tract infections.

One RCT (-)¹ (UK; n=807) conducted in a primary care setting found that providing patients (with acute lower respiratory tract infection) with an information leaflet about the natural history of the condition, had no significant effect on antibiotic use (p=0.58), satisfaction with treatment (p=0.24) or belief in antibiotics (p=0.73) when compared to no leaflet. Patients in this study were also randomised to receive no prescription, delayed prescription or immediate prescription, but leaflet vs. no leaflet results were not presented within each of these prescribing practices.

One nested-RCT² (+) (UK; n=212) found that an information leaflet about the natural course of lower respiratory tract symptoms and the advantages/disadvantages of antibiotic use provided to patients with acute bronchitis who were judged by their GP not to need antibiotics but given a prescription with the advice that they did not need it, significantly reduced inappropriate antibiotic use. Patients in the intervention were significantly less likely to take the antibiotics prescribed compared with patients in the control, who received standard care (RR 0.76 [95%CI: 0.59 to 0.97], p=0.04).

Applicability:

While one of the studies was not conducted in the UK, the evidence is directly applicable to people in the UK as there are no obvious differences in the population, context or setting of the study compared with the UK context.

[1] Little et al. 2005 (-)

[2] Macfarlane et al. 2002 (+)

Interventions Based in the Accident and Emergency (A&E) Department of a Hospital Targeting Patients or Parents of Paediatric Patients

Evidence Statement 1.6: Interactive Computerised Education Module Based in A&E Targeting Patients

There is weak evidence from one pre-post study (-)¹ (USA; n=686) that an educational interactive computerised kiosk situated in an A&E department reduced the desire for antibiotics in patients presenting with acute respiratory infection (ARI). This study found that the proportion of patients with a low desire for antibiotics increased after completing the module, from 22% to 49% (p<0 .001), and that the proportion who strongly wanted antibiotics decreased from 34% to 27% (p<0.001). Change in desire was positively associated with self-report of having learnt something new at the end of the module (aOR 1.67 [95%CI: 1.14 to 2.45]).

Applicability:

The evidence is partially applicable to people in the UK. This is because the population attending A&E for acute respiratory infections in the USA may be more likely to be uninsured and to have lower socioeconomic status; in those respects it may differ from the population in the UK.

[1] Price et al. 2011 (-)

Evidence Statement 1.7: Video or Information Leaflet Based in A&E Targeting Parents of Paediatric Patients

There is weak evidence from one RCT (-)¹ (USA; n=337) that an animated video or information pamphlet delivered in an emergency department of a hospital significantly increased parents' mean rank self-reported knowledge score of appropriate antibiotic use immediately post intervention and at four-weeks follow up, compared to controls. There was no difference in mean score between the video and pamphlet group post intervention (p=0.19) but the video group performed significantly better at four-weeks follow up (p=0.04). The video group was also significantly less likely to report that they would ask paediatrician for antibiotic if their child had an illnesses (such as cold and fever) that had been discussed during the intervention than the pamphlet group: 35.4% vs. 14.5%, respectively (p=0.003).

Applicability:

The evidence is partially applicable to people in the UK. This is because the population attending A&E for acute respiratory infections in the USA may be more likely to be uninsured and to have lower socioeconomic status; in those respects it may differ from the population in the UK.

[1] Schnellinger et al. 2010 (-)

Intervention Based in the Home Led by Researchers Targeting the Latino Community

Evidence Statement 1.8: Culturally Appropriate, Home-Based Educational Intervention Targeting Latino Population

There is weak evidence from one pre-post study¹ (+) (USA; n=422 analysed) that a culturally sensitive home-based educational intervention can increase participants' knowledge of whether it is appropriate to take antibiotics for a cold, sore throat, asthma and influenza (p<0.01 for each).

Applicability:

The evidence is partially applicable to the wider UK population, as the study population may differ from the population in the UK. The intervention could be conducted in the UK context and is likely to be relevant to other ethnic minority groups as well.

[1] Larson et al. 2009 (+)

Interventions Based Within Primary or Secondary Schools and/or Targeting School Aged Children

Evidence Statement 1.9: School-Based Interventions Led by a Teacher Targeting School Children or Interventions Targeting School Aged Children

There is inconsistent evidence from four pre-post studies—three (-)¹,²,⁴ and one (+)⁵—and one RCT (-)³ concerning whether school-based interventions can positively impact on students' knowledge and understanding of the concepts of bacteria, antimicrobials and appropriate antimicrobial use.

One pre-post study¹ (-) (UK; n=1736 [school n=62, online n=1674]) found that an e-Bug-developed "junior student"-level computer game for 9- to 12-year-old children did not significantly change students' knowledge of appropriate antibiotic use (e-Bug is a Europe-wide antibiotic and hygiene teaching resource).

Two pre-post studies (-)² (+)³ (UK; n=48 and n=251, respectively) found that a two-day workshop titled Antibiotics and Your Good Bugs, for children 9 to 10 years of age, or a "Bug Investigators" pack, for children 10 to 11 years of age, effectively improved knowledge of microbes/infection and antibiotics and appropriate antibiotic use but did not have any effect on awareness of AMR.

One pre-post study⁴ (-) (Portugal; n=42) found that a one-week hands-on programme, whose title translates as Microbiology Recipes: Antibiotics à la carte, for high school students aged 15 to 16 years old significantly improved students' knowledge of bacteria and antibiotics, appropriate antibiotic use and awareness of AMR (p<0.05 improvement on all questions).

One RCT⁵ (-) (Italy; n=249) found that an educational food safety campaign, whose title translates as Mission on the Invisible World (which included information on bacteria), did not significantly progress the students' knowledge of "insight into flu and antimicrobial resistance" (p-values were not reported).

Applicability:

While two of the studies were not conducted in the UK, the evidence is directly applicable to people in the UK, as there are no obvious differences in the population, context or setting of the study compared with the UK context.

[1] Farrell et al. 2011 (-)

[2] McNulty et al. 2001 (-)

[3] McNulty et al. 2007 (+)

[4] Fonseca et al. 2012 (-)

[5] Losasso et al. 2014 (-)

Intervention Based in Day Care Centre Led by Health Educator/Child Care Provider Targeting Parents

Evidence Statement 1.10: Day Care-Based Intervention Led by Health Educators/Child Care Providers Targeting Parents

There is weak evidence from one RCT¹ (-) (USA; n=659) that the provision of educational materials (brochures, leaflets, colouring sheets and handouts on appropriate antibiotic use) disseminated by care workers may lead to improvements in knowledge of appropriate antibiotic use among parents with a college education (9-point knowledge median score pre vs. post intervention: 7 vs 6.5, p<0.01), but not for parents without a college education (median score 6 vs 6, p=0.20).

Applicability:

While the study is not set in the UK, the evidence is directly applicable to people in the UK, as there are no obvious differences in the population, context or setting of the study compared with the UK context.

[1] Croft et al. 2007 (-)

Interventions Implemented Within the Community

Evidence Statement 1.11: Mass Media Campaign (Advertisements in Magazines and Newspapers, Posters and Leaflets) at the Community Level

There is weak evidence from two US studies (one cluster RCT (+)¹ and one non-RCT (-)²) indicating that media campaigns delivered within a community setting have no effect on a community's knowledge of antibiotics, demand for antibiotics, or use of antibiotics without a prescription.

One cluster RCT¹ (+) (USA; 2000 n=nr; 2003 n=5580) involved a multicomponent educational intervention consisting of six mailed newsletters highlighting misconceptions about antibiotic use for conditions such as colds sent to low-risk patients, as well as other educational materials (stickers, posters, information leaflets and fact sheets) made available in waiting rooms of local paediatric providers, pharmacies and child care centres, versus nothing in the control communities. There was no significant improvement in knowledge scores or demand for antibiotics in intervention communities compared with control communities (aOR 1.2 [95%CI: 0.8 to 1.7]). In subanalysis, however, a significant impact was observed by insurance provider: the proportion of parents with high antibiotic knowledge significantly increased among parents of Medicaid-insured children (aOR 2.2 [95%CI: 1.1 to 4.5]), but not among parents of non-Medicaid-insured children (aOR 1.0 [95%CI: 0.6 to 1.4]).

One non-RCT² (-) (USA; pre-intervention n=273, post-intervention n=293, control post-intervention n=306) showed that a mass media campaign specifically targeting a Latino population was not effective in decreasing the number of antibiotics bought without a prescription in the past 12 months (OR 0.85 [95%CI: 0.27 to 2.63]) and was ineffective at changing participants' beliefs that antibiotics should not be available without a prescription; 30.6% in the intervention community believed they should be available without a prescription before the intervention, compared with 48.0% after and 35.8% in the control post-intervention (p<0.05).

Applicability:

The evidence is only partially applicable to people in the UK. This is because the study populations in these studies or the services available to them may differ from those in the UK. It should be noted that antibiotics cannot be legally obtained in the UK without a prescription.

[1] Huang et al. 2007 (+)

[2] Mainous et al. 2009 (-)

Evidence Statement 1.12: Mass Media Campaign (Information Leaflet, Posters, Nurse Educators, Newspaper Articles) and GP Intervention Targeting Parents at the Community Level

There is weak evidence from one RCT¹ (-) (USA; n=430) that a community-based intervention involving an information leaflet ("Your Child and Antibiotics"), posters, nurse educators, newspapers articles, and a GP intervention to promote appropriate antibiotic use was effective at increasing parents' knowledge of AMR.

The difference in change in knowledge from baseline to post-intervention was significantly greater for the intervention group than the control, namely, 10% ([95%CI 1.9 to 18.1] p=0.015). In terms of decreasing parents' desire for antibiotics for their child, the change in desire from baseline to post-intervention was significantly greater for the intervention, namely, –8.4% (–13.9 to –2.8) (p=0.003). The evidence related to parents' understanding of when to use antibiotics was less clear; at post-intervention the mean score was significantly lower (better) in the intervention area than control (2.7 vs 3.5, p<0.001); however, the change from baseline for the intervention and control groups was not significantly different (–1.1 vs –0.8, p=0.07).

Applicability:

While the study was not conducted in the UK, the evidence is directly applicable to people in the UK as there are no obvious differences in the population, context or setting of the study compared with the UK context.

[1] Trepka et al. 2001 (-)

Interventions Targeting the General Public

Evidence Statement 1.13: Interactive Science Show Based in a Holiday Resort Targeting Families with Children

There is weak evidence from one pre-post study¹ (+) (UK; n=406) that a science show and interactive stalls based on the e-Bug educational packs can significantly improve knowledge of antibiotics, knowledge of appropriate antibiotic use (e.g. not keeping antibiotics for later use), and AMR in children aged 5 to 11 years old. Children's knowledge significantly improved for all questions; overall, the percentage of children correctly answering questions increased by 25% (p<0.001). For parents the impact was less marked; knowledge increased for all three questions related to antibiotics and for one of the two questions related to AMR, but not for questions related to antibiotic use. However, baseline knowledge was 95% for both questions.

Applicability:

The evidence is directly applicable to parents and children in the UK.

[1] Lecky et al. 2014 (+)

Evidence Statement 1.14: Web Based Educational Intervention Targeting the General Public

There is weak evidence from one pre-post study¹ (-) (UK; n=277) that a health information website significantly improved peoples' attitudes towards prescribing (i.e. expectation of being prescribed antibiotics for acute otitis media decreased), but that, overall, it did not significantly improve peoples' awareness of AMR (significant for only three out of seven statements tested) or improve knowledge of appropriate antibiotic use (e.g. taking a full course) (significant for only three out of the six statements tested).

Applicability:

While the study was conducted in the UK, it may not be directly applicable to the wider population given that it was conducted in a museum setting and almost a quarter of respondents were doctors.

[1] Madle et al. 2004 (-)

Evidence Statement 1.15: Mass Media (Advertisements in Magazines and Newspapers, Posters and Leaflets) and GP Interventions at the Population Level

There is weak evidence from three pre-post studies (-)¹,²,³ and one repeated cross-sectional survey (-)⁴ that mass media campaigns targeting the general public do not have an effect or have only a small effect on knowledge of and attitudes towards appropriate antibiotic use.

A pre-post study¹ (-) (New Zealand; 1998 n=282, 2003 n=387) that collected information on public views and use of antibiotics for colds in adolescents and adults in 1998 and subsequently from 2002 found that the national campaign did not change the public's understanding of antibiotic efficacy against viral infections (41% vs. 38% p=0.9). When specific symptoms were evaluated, however, there was significantly improved knowledge of appropriate antibiotic use for six out of the 13 symptoms. Despite limited impact on knowledge, however, the number of respondents reporting that they consulted a doctor about a cold or flu significantly decreased from 62% to 45% (p<0.001).

One pre-post study (with control post-intervention)² (-) (UK; 2008 n=1888 [England=1706, Scotland=182; 2009 n=1830[England=1707, Scotland=123]) reported that the 2008 English public antibiotic poster campaign had no impact on the proportion of incorrect answers among English respondents to the statement "Antibiotics work on most coughs and colds". The incorrect response decreased from 40% in 2008 to 37% in 2009, p=0.30. Compared with Scotland, there was no significant difference for nine out of ten questions related to attitudes towards antibiotic use. Self-reported changes in use of antibiotics did not significantly change for two out of the three measures; the number of English respondents reporting that they kept left-over antibiotics significantly increased, from 2.2% to 7.0%, p<0.001. Compared with Scotland, self-reported changes in use did not significantly differ for two out of the three measures.

One pre-post study³ (+) (UK; 1999 n=982, 2000 n=1941) found that a nationwide public education campaign known as CATNAP (Campaign on Antibiotic Treatment and the National Advice to the Public) that promoted the need to cherish and preserve your normal bacterial flora, locally enhanced to include more channels of promotion, did not significantly change the public's knowledge of appropriate antibiotic use. There was no change for all seven of the general questions posed, while for questions related to appropriate antibiotic use among children, a significant change was only observed for one out of the five questions—the proportion of adults who agreed that children should be prescribed antibiotics for fever significantly decreased, from 56% to 49% (follow-up difference –7% [one-sided 95%CI: –13.5]).

A repeated cross-sectional survey⁴ (-) (Australia; 1999 n=1614; 2000 n=1603; 2001 n=1800; 2003 n=1200; 2004 n=1200) reported on a community campaign to reduce inappropriate use of antibiotics for the common cold in adolescents and adults. There was a significant decline in those who believed taking antibiotics for cold and flu is appropriate, from 28.7% pre-programme in 2002 to 21.7% in 2004 (percentage-point change 7.0 [95%CI: 3.5 to 10.5]). A comparison of successive yearly consumer surveys revealed a significant decrease in self-reported use of antibiotics to treat a cough, a cold or the flu, from 10.8% in 1999 down to 7.4% in 2004 (percentage-point change 3.4 [95%CI: 1.3 to 5.5]).

Applicability:

Two of the studies were conducted in the UK. The other two studies are directly applicable to people in the UK as there are no obvious differences in the population, context or setting in these studies compared with the UK context.

[1] Curry et al. 2006 (-)

[2] McNulty et al. 2010 (-)

[3] Parsons et al. 2004 (+)

[4] Wutzke et al. 2007 (-)

Research Question 2: Infection and/or Hand Hygiene

Interventions Based in Healthcare Setting

Evidence Statement 2.1: Healthcare Centre-Based Intervention Led by Nurses Targeting Veterans with Spinal Cord Injuries and Disorders

There is weak evidence from one pilot RCT study¹ (-) (USA; n=69) that a nurse-administered patient educational intervention about methicillin-resistant Staphylococcus aureus (MRSA) in veterans with spinal cord injuries and disorders does not alter participants' knowledge of MRSA (p=0.81) or their self-reported hand hygiene behaviours following such activities as using the toilet (p=0.83); it may, however, improve participants' perception that the intervention altered their hand hygiene behaviour (p=0.02).

Applicability:

The evidence is partially applicable to people in the UK population, as the population in this study is likely to differ from the wider UK population.

[1] Evans et al. 2014 (-)

Evidence Statement 2.2: Waiting Room of A&E Based Intervention Targeting Paediatric Patients and Their Parents

There is weak evidence from one pilot RCT ¹ (-) (USA; paediatric patients n=60, parents n=57) that hand hygiene education, with or without the use of Glo Gel (to show unclean hands under black light) in a hospital emergency department setting, significantly improved hand cleanliness in paediatric patients pre to post intervention 16.3 (±3.66) to 17.9 (±3.91), with a mean improvement score of 1.60 (±4.7) (p=0.02); there was no significant difference between the groups (p=0.82). For adults there was no significant difference between pre and post intervention (mean improvement score 0.46 (±5.03), p=0.55).

There was also a significant improvement among paediatric patients from pre to post intervention for self-reported washing hands of with warm water (70% vs. 85%, p=0.01) but no difference in other behaviours (i.e. wash hands before dinner; wash hands after bathroom). There was no difference between intervention and control for any self-reported behaviour outcomes (p>0.6 for all three questions). There was no difference from pre to post intervention or between the intervention and control in parents' self-reported hand hygiene behaviour (p>0.9 for all), but baseline compliance with hand hygiene behaviour was high.

Applicability:

The evidence is partially applicable to people in the UK population, as the population attending A&E for acute respiratory infections in the USA may be more likely to be uninsured and to have lower socio-economic status; in those respects it may differ from the population in the UK

[1] Fishbein et al. 2011 (-)

Intervention Based in the Home Led by Researchers Targeting the Latino Community

Evidence Statement 2.3: Culturally Appropriate, Home-Based Educational Intervention Targeting Latino Population

There is weak evidence from two pre-post (+)¹ (-)² that a culturally appropriate, home-based educational intervention significantly improved knowledge of respiratory infection prevention and improved hand hygiene behaviour (i.e. use of sanitizer) and uptake of influenza vaccination in urban Latinos.

One pre-post study¹ (+) (USA; n=422 analysed at end) found that a culturally sensitive, home-based educational intervention led to improved mean composite knowledge scores (out of 10) from 5.19 (±1.60) pre-intervention to 5.91 (±1.71) post-intervention (p<0.001). While the proportion of participants reporting that they use alcohol-based hand sanitizer some of the time increased from 1.4% to 66.8% (p<0.001), the proportion washing with antibacterial soap decreased from 45.3% to 24.9% (p<0.001). Finally, there was a reported increase in the number of households with one or more members receiving an influenza vaccination, from 63.7% to 73.9% (p<0.001).

One pre-post study² (-) (USA; n=509) reported significant improvements in households' knowledge of prevention and treatment strategies for all three interventions, namely, (1) education only; (2) education and hand sanitizer; and (3) education, hand sanitizer and face masks. The change in knowledge score was significantly greater for the education and hand sanitizer group compared with the other groups, from 5.48 to 7.24 (out of a score of 10) (p<0.001). Likewise, while rates of vaccination increased in all three groups, it was greatest in the education and hand sanitizer group compared with the other groups, increasing from 19.0% to 57.1% (p<0.001).

Applicability:

The evidence is partially applicable to the wider UK population, as the studies' populations may differ from the population in the UK, although the intervention could be conducted in the UK context and is likely to be relevant to other ethnic minority groups.

[1] Larson et al. 2009 (+)

[2] Larson et al. 2010 (-)

Interventions Based Within Pre-School or Primary Led by a Teacher Targeting Young Children

Evidence Statement 2.4: Preschool- or Primary School-Based Interventions Involving Appropriate Hand Hygiene Instruction and Other Educational Activities

There is weak evidence from two pre-post studies (-)² (-)³ and one cluster RCT (-)¹ that hand hygiene instruction, with additional educational activities, may improve hand hygiene behaviour in preschool and primary school children.

One cluster RCT¹(-) (Switzerland; n=61) found that hand and nail hygiene instruction in kindergarten classes, for children aged 4 to 6 years old, had a limited effect in improving hand cleanliness (0% both hands clean to 100% both hands dirty) among children who received the intervention, from 34% to 22% (p=0.30) four weeks after the intervention, but that it did have a significant impact on nail hygiene (0% both sides of all 10 fingers clean to 100% both sides of all 10 fingers dirty), which improved from 68% to 53% (p=0.007) among children. The authors reported that the observed improvements for both hand and nail hygiene were significantly greater among children in the intervention than control (p-values were not reported). We note that the way in which the results are presented by the authors is not clear.

One pre-post study²(-) (USA; n=406) reported that parents and teachers observed a positive improvement in the hand hygiene of children attending the second grade of primary school over the course of a four-week, multicomponent education programme, broadly involving appropriate hand washing education, a UV fluorescent glow which allowed the children to observe how well they had washed hands, teacher-student discussions and a range of materials (e.g. stickers, colouring sheets): 64% of parents and 94% of teachers reported that the frequency of hand washing increased (p-values were not reported).

One pre-post study³ (-) (USA; n=35) found that a day care-based intervention for children aged 3.5 to 5 years old, involving hand washing instruction, the Glo Germ UV light, singing, a story, and a video, improved hand washing behaviour in preschool children: the use of soap was observed to increase from 54% to 87%, and rubbing hands together for more than ten seconds increased from 20% to 53% (p-values were not reported). Parents of the children perceived that children's understanding of the relationship between germs and hand washing increased.

Applicability:

While none of the studies were conducted in the UK, the evidence is directly applicable to people in the UK as there are no obvious differences in the population, context or setting of the study compared with the UK context.

[1] Ramseier et al. 2007 (-)

[2] Tousman et al. (2007) (-)

[3] Witt and Spencer 2004 (-)

Evidence Statement 2.5: Primary School-Based Interventions Involving Appropriate Hand Hygiene and Respiratory Etiquette, and Placement of Hand Sanitizers for Teachers and Students

There is weak evidence from one cluster RCT (-)¹ (USA; n=167) that a multicomponent educational intervention may improve hand hygiene behaviour, hygiene etiquette and knowledge of germs in primary school students.

The intervention involved educating teachers and students about appropriate hand hygiene, hand etiquette, and "cover your cough" behaviours; providing information about "germs" and influenza; and placing hand sanitizer in all classrooms and common areas.

The average number of times students washed/sanitized their hands per day was 3.95 in the intervention school vs 3.08 in the control school (p=0.014). Appropriate behaviour related to covering coughs and sneezes was higher in intervention than control schools: 3.76 vs 3.29, p=0.002. Students in the intervention schools also had improved knowledge of how to stop the spread of germs (p<0.001).

Applicability:

While this study was conducted in the USA, there are no obvious differences in the population, context or setting of the study compared with the UK.

[1] Stebbins et al. 2010 (-)

Interventions Based in Schools and/or Targeting Children Nine Years of Age or Older

Evidence Statement 2.6: E-Bugs Educational Interventions Targeting Children 9 Years of Age or Older

There is inconsistent evidence from five studies (four pre-post studies (-)¹,²,⁴ (+)⁵ and one non-RCT (-)³ concerning whether or not e-Bug-based interventions improve knowledge of microbes, awareness of infection, infection prevention and/or hand hygiene among children aged 9 to 15 years old.

One pre-post study¹ (-) (UK; n=1736 [school n=62, online=1674]) found that an e-Bug computer game for 9- to 12-year-old children did not lead to a significant improvement in children's knowledge of microbes/infection/hand hygiene. Knowledge significantly changed for only 3 out of 21 questions: 2 related to knowledge of microbes (p=0.001 and p=0.02) and 1 related to the benefits of using soap (p=0.02).

One pre-post study² (-) (UK; n=225) found that, following a modified e-Bug lesson plan, 9- to 11-year- old children showed a significant improvement in overall knowledge of microbes, hand hygiene and farm hygiene (p<0.001). However, improvements were not shown for all questions within each topic.

One non-RCT study³ (-) conducted in the Czech Republic, England and France, found that the e-Bug educational pack focussing on knowledge of prudent antibiotic use and hygiene significantly improved children's "knowledge of infection" in some countries/regions, but not in others. In England (n=2136), knowledge of microbes, of how infections are spread, and how to treat and prevent infection did not significantly differ in junior school children (9- to 11-year-olds) exposed to the intervention compared with children in the control schools. But the authors reported that there were significant improvements among senior school children (12- to 15-year-olds) for all outcomes immediately following the intervention and at six months follow up (p-values were not reported).

One pre-post study⁴ (-) (UK; n=48) found that a two-day workshop titled Antibiotics and Your Good Bugs, for children aged 9 to 10 years old, did not significantly increase the number of children who correctly identified the need to wash their hands after various activities. However, baseline values were high: the overall score increased from 94% to 96% (p=0.5).

One pre-post study⁵ (+) (UK; n=251) found that use of a "Bug Investigators" pack for children aged 10 to 11 years old resulted in a significant increase in the proportion of children who correctly identified that they needed to wash their hands after all 10 activities presented, from 90% to 94% (p<0.001).

Applicability:

While one of the studies included study sites outside of the UK, the evidence is directly applicable to people in the UK, as there are no obvious differences in the population, context or setting of the study compared with the UK context.

[1] Farrell et al. 2011 (-)

[2] Hawking et al. 2013 (-)

[3] Lecky et al. 2010 (-)

[4] McNulty et al. 2001 (-)

[5] McNulty et al. 2007 (+)

Evidence Statement 2.7: School-Based Educational Interventions Targeting Children 9 Years of Age or Older

There is weak evidence from one pre-post study (-)¹ and one RCT (-)² that school-based interventions can improve hand washing behaviour.

One pre-post study¹ (-) (USA; n=73) found that a five-week hygiene intervention programme called High Five for Healthy Living was effective in improving hand washing behaviour in 11- to 14-year-olds (predominantly African American) attending an afterschool club; 67% of students improved their test scores by 10% (p-values were not reported).

One RCT (-)² (Italy; n=249) found that an educational programme involving multimedia and movies taught in either a practical or a theoretical class, targeting fifth grade students (aged 9 to 11 years old), significantly improved appropriate hand hygiene behaviour in both classes (Incidence Risk Ratio (IRR) 3.4 [95%CI: 2.2 to 5.2]) and 3.2 [95%CI: 1.9 to 5.5]), but did not improve knowledge of hand hygiene in either class (IRR 1.1 [95%CI: 1.0 to 1.2] and 1.0 [95%CI: 0.9 to 1.2]).

Applicability:

While neither study was based in the UK, the evidence is directly applicable to people in the UK, as there are no obvious differences in the population, context or setting of the study compared with the UK context.

[1] Baker et al. 2012 (-)

[2] Losasso et al. 2014 (-)

Interventions Based in a University Setting

Evidence Statement 2.8: Poster Campaigns Displayed in University Restrooms

There is inconsistent evidence from one RCT (-)¹, one pre-post study (-)² and one non-RCT (-)³ concerning whether or not posters placed in public toilets in university buildings improve the frequency of hand washing or the use of soap, but there does appear to be a significant increase in the use of hand sanitizer.

One RCT¹ (-) (USA; n=252 observations, n=95 surveys) conducted in public toilets on a university campus found that posters with different descriptive norm messages (a high-prevalence message: "Four out of five college students wash their hands EVERY time they use the bathroom." or a low-prevalence message: "One out of five college students wash their hands EVERY time they use the bathroom.") led to a significant increase in the frequency (low prevalence vs. no poster aOR 19.39 p=0.006; high prevalence vs. no poster aOR 6.53 p=0.033) and length of time that participants washed their hands in seconds (high prevalence 9.94 (±7.78), low prevalence 9.57 (±7.78), no poster 6.04 (±7.58), p=0.04) compared to no poster, but not for use of soap (p=0.54). Positive attitudes towards hand washing were significantly greater for the high and low prevalence message compared to no message (p=0.01).

One pre-post study² (-) (USA; n=1,005 observations, n=188 surveys) found that a hand hygiene poster campaign targeting university students did not increase observed rates of hand washing but did significantly increase the use of soap during hand washing, from 58.0% to 78.1% (p<0.001). Women were observed to wash their hands and use soap significantly more frequently than men (90% vs 80%, p<0.001).

One non-RCT³ (-) (USA, n=not measured) conducted in public buildings on a university campus found that signs promoting hand hygiene placed next to a hand sanitizer significantly increased hand sanitizer use. Depending on the framing of the message on the sign, the usage increase ranged from 40.6% to 66.4% compared to dispensers with no sign (p<0.01). The greatest usage was observed when the message "Stay healthy this season. Sanitize your hands" was placed next to dispensers and the smallest increase was for the message ("Germs are out to get you. Get them first!". The signs had a consistent influence on usage over time and were not significantly moderated by temporal trends (p>0.10).

Applicability:

While the studies were not conducted in the UK, the evidence is directly applicable to people in the UK, as there are no obvious differences in the population, context or setting of the study compared with the UK context.

[1] Lapinski et al. 2013 (-)

[2] Mackert et al. 2013 (-)

[3] Updegraff et al. 2014 (-)

Evidence Statement 2.9: Message Campaign and Hand Sanitizer Targeting University Students

There is weak evidence from one non-RCT (-)² and one non-RCT (-),¹ indicating that university-based poster campaigns, with the provision of hand sanitizer and/or a researcher interacting with students, can lead to an increase in the rates of hand washing with had sanitizer and an increase in frequency of hand washing per day.

One non-RCT¹ (-) (USA; n=6454) evaluated the impact of an information poster ("Sanitize your hands to prevent cold and flu") placed next to cashier counter en route to a food and drink service in a cafeteria, access to hand sanitizer, and a researcher promoting hand hygiene, compared with the poster and sanitizer alone. On days when all three interventions were implemented, the percentage of students using hand sanitizer was high (60%) compared with those days when only two components were implemented (15 to18%) (p-values were not reported).

One cluster non-RCT² (-) (USA; n=430) found that a poster campaign detailing the "Top 10 gross things students have on their hands", coupled with free hand sanitizer, posted in student halls of residence, effectively improved students' knowledge of the role of hand hygiene in infection control. While students' perceived frequency of engaging in hand hygiene did not differ between the intervention and control, the reported rates of weekly hand washing (students provided weekly reports documenting hand washing activity) were significantly higher among intervention students than controls; 0.48 vs 0.43 times per hour, p<0.02.

Applicability:

While none of the studies are set in the UK, the evidence is directly applicable to people in the UK, as there are no obvious differences in the population, context or setting of the study compared with the UK context.

[1] Fournier and Berry 2012 (-)

[2] White et al. 2003, 2005 (-)

Interventions Targeting the General Public

Evidence Statement 2.10: Web-Based Interactive Module Targeting the General Population

There is weak evidence from one RCT¹ (+) (UK; n=517) that a web-based interactive module conducted over four weeks significantly improved self-reported rates of hand washing in adults and that the improvements were sustained eight weeks after the intervention (on a scale of 1[zero to two times per day] to 5 [more than ten times per day]): 4.45 in intervention vs 4.12 in the control (p<0.001). The intervention also increased positive attitudes, and intentions of hand washing, when compared with controls who received no intervention.

Applicability:

The evidence is directly applicable to the UK population.

[1] Yardley et al. 2011 (+)

Evidence Statement 2.11: Mass Media Campaign Targeting the General Population

There is weak evidence from one pre-post study¹ (+) (Germany; 2008 n=2006, 2009 n=2006), which investigated perceptions of hand hygiene before and after a public campaign titled Wir gegen Viren [Us Against Viruses], that the perceived efficacy of hand hygiene and coughing into the sleeve as an infection control method increased over time among the general public: aOR 1.54 [95%CI: 1.31 to 1.80] and aOR 13.07 [95%CI: 10.00 to 17.08], respectively.

Applicability:

While the study was not conducted in the UK, the evidence is directly applicable to people in the UK, as there are no obvious differences in the population, context or setting of the study compared with the UK context.

[1] Meilicke et al. 2013 (+)

Research Question 2: Hygiene and/or Food Safety

Intervention Based in the Home Led by a Community Facilitator Targeting Adults Living in a "Deprived" Community

Evidence Statement 3.1: Home-Based Interventions Targeting Adults from a "Deprived" Community

There is weak evidence from one pre-post study¹ (+) (UK; n=904) that a home-based food storage education intervention targeting adults living in a deprived community, provided by a community-based facilitator, effectively improved peoples' knowledge of and behaviour around appropriate refrigeration. The proportion of respondents who identified, and had their fridge set at, the correct operating temperature increased from 31.7% to 78.4% (p<0.01) and 69.3% to 84.2% (p=0.03), respectively; the proportion of refrigerators containing food past its "use by date" significantly decreased, from 10.1% to 5.2% (p=0.03), and the proportion of refrigerators in which raw meat and cooked food were stored incorrectly decreased from 16.2% to 7.1% (p=0.04) and 14.7% to 7.2% (p<0.05), respectively.

Applicability:

The evidence is partially applicable to the wider UK population, as the study population was a deprived community, and therefore may differ from the wider UK population.

[1] Ghebrehewet and Stevenson 2003 (+)

Interventions Based in Schools and/or Targeting School Aged Children

Evidence Statement 3.2: Primary School-Based Interventions Targeting School Children or Interventions Targeting School-Aged Children

There is inconsistent evidence from two pre-post studies (-)¹ (-)² and one RCT (-)³ that school-based educational interventions have an impact on children's knowledge of appropriate food handling.

One pre-post study¹ (-) (UK; n=1736 [school n=62, online=1674]) found that an e-Bug computer game for 9- to 12-year-old children did not improve children's knowledge of appropriate food handling, as assessed by means of three questions.

One pre-post study² (-) (USA; n=300) found that a web-based food safety programme targeting middle school students (approx. 10 to 13 years of age) had a significant impact on mean knowledge food safety score for students in grade seven (52.2% (±15.19) vs. 65.2% (±16.44), p<0.001) and eight (49.8% (±16.83) vs. 60.1% (±20.35), p<0.001) but not among students in grade six 56.0% (±15.62) vs. 56.0% (±20.12) p=ns). How far the student progressed through the programme's required lesson and the total usage of the programme were both significantly correlated with learning achievement: r2=0.065, p<0.00, and r2=0.0353, p=0.005 respectively.

One RCT³ (-) (Italy; n=249) found that an educational programme involving multimedia and movies taught in either a practical or a theoretical class, targeting students aged 9 to 11 years old, significantly improved knowledge of appropriate "food handling" among children attending a practical class (IRR 1.1 [95%CI: 1.0 to 1.3], p<0.001) but not among children attending a theory-based learning class (IRR 1.0 [95%CI: 0.9 to 1.1]).

Applicability:

One study was conducted in the UK, and the other was conducted in Italy. In the latter study, there are no obvious differences in the population, context or setting of the study compared with the UK.

[1] Farrell et al. 2011 (-)

[2] Lynch et al. 2008 (-)

[3] Losasso et al. 2014 (-)

Evidence Statement 3.3: Summer Enrichment Programme Targeting School Children

There is weak evidence from one pilot pre-post study¹ (-) (USA; n=22) that an education programme provided to youth aged 6 to 16 years old from low-income families may have effectively improved knowledge of food-borne illness and food safety across all survey questions asked. For example, knowledge of the importance of washing hands before handling food increased by 76% among 13- to 16-year-olds and by 91% among 6- to 12-year-olds (p-values were not reported), and knowledge that harmful bacteria are found in raw poultry and unpasteurised milk increased by 77% among 13- to 16-year-olds, but by only 9% among 6- to 12-year-olds.

Applicability:

While the study was not conducted in the UK, the evidence is likely to be partially applicable to the UK population as the study population may differ from the wider UK population.

[1] Comer (2002) (-)

Interventions Based in a University Targeting Students

Evidence Statement 3.4: University-Based Interventions Targeting Students

There is weak evidence from one non-RCT (+)¹ and two pre-post studies (-)²,³ that food safety campaigns targeting students at university significantly improved food safety knowledge, attitudes and practice.

One non-RCT study¹ (+) (USA; n=710) found that a multicomponent university campaign involving food safety lectures and/or a Facebook fan page for online food safety education significantly increased knowledge scores from pre- to post-intervention for students in the intervention (p<0.05) but not the control (p=0.06). The change in knowledge was significantly greater among students who took the lecture compared with students who only looked at Facebook (p-values were not reported). The change in attitude was significantly greater in all intervention groups compared with the control (p-values were not reported). Change in food safety practices was significant from pre- to post-intervention for all groups, including the control (p<0.05); the group who just received the lecture had significantly lower scores than the groups who accessed the Facebook fan page (p-values were not reported).

One pre-post study² (-) (USA; n=1,159) found that a food safety campaign effectively improved most food safety knowledge measures of students (with the exception of hand washing procedure): overall mean scores (on a scale of 1 to 8) significantly increased, from 3.29 (1.61) to 4.17 (1.84) (p<0.001) and the campaign significantly improved students' use of soap before cooking (p<0.001) and after using the toilet (p<0.001).

One pre-post study³ (-) (USA; n=71) found that an interactive computer module had a significantly positive impact on students' food safety attitude scores, which increased from 114.5 to 122.2 out of a possible 147 points (p0.001). Beliefs scores increased from 85.8 to 97.6 out of a possible 119 points (p0.001) and self-reported food safety practices increased from 19.0 to 21.0 out of a possible 27 points (p=0.001). In subgroup analysis, health majors outperformed non-health majors across all three measures (p<0.05).

Applicability:

While none of the studies were conducted in the UK, the evidence is directly applicable to people in the UK. There are no obvious differences in the population, context or setting of the study compared to the UK context.

[1] Bramlett Mayer and Harrison 2012 (+)

[2] Maurer Abbot et al. 2012 (-)

[3] Yarrow et al. 2009 (-)

Interventions Based Within the Community

Evidence Statement 3.5: Community-Based Interventions Targeting Parents

There is weak evidence from two RCTs (-)¹,³ and one cluster non-RCT (-)² that workshops or a multimedia intervention targeting parents result in modest improvements in food safety behaviour.

One RCT¹ (-) (USA; n=168) found that a workshop including topics on food safety (in addition to other topics) improved self-reported food safety behaviour among low-income parents. It is not clear how effective this intervention was compared with the control group, who received the intervention at a later time point to those in the intervention group, because results are presented pre-post intervention within each group: for those who received immediate education the mean score (on a scale of 1 to 50) increased from 34.9 to 42.8 (p-values were not reported), while for those who received the education later it increased from 35.4 to 42.8 (p-values were not reported).

One cluster non-RCT² (-) (USA; n=600 analysed at end) found that a mass media campaign involving traditional mass media (such as posters and radio advertisements) and newer social media methods, including YouTube videos and an iPhone/iPad application, had a significant impact on food safety behaviour (e.g. appropriately throwing away leftovers) among those in the intervention communities compared with those in the control; 50% vs 38% (p=0.009).

One RCT³ (-) (USA n=394) found that a multimedia intervention (computer kiosk) or information leaflets given to pregnant women and mothers improved the overall food safety score for women in both groups (on a scale of 1 to 5). The interactive multimedia group increased from 3.8 to 4.1; the leaflet group increased from 3.8 to 3.9. The difference in change between groups was only significant when controlling for age, though the size of the effect was small (p=0.03).

Applicability:

While none of the studies were conducted in the UK, the evidence is directly applicable to people in the UK. There are no obvious differences in the population, context or setting of the study compared with the UK context.

[1] Dollahite et al. 2014 (-)

[2] James et al. 2013 (-)

[3] Trepka et al. 2008 (-)

Evidence Statement 3.6: Classes for Youths and Adults

There is weak evidence from one pre-post study¹ (-) (USA; n= 602 [youths=229 youths, adults=373]) that food preparation classes provided to youths and adults are effective in improving all of the safe food handling behaviours tested. The proportion reporting that they washed their hands before preparing food increased by 38% for youths and 11% for adults (p<0.001 for both); likewise, the proportion reporting that they washed fresh fruits and vegetables before preparation increased by 29% for youths and 8% for adults (p<0.001 for both) and the proportion using a clean knife and cutting board to prepare fruits or vegetables to avoid cross-contamination increased by 36% for youths (p<0.001) and 7% of adults (p=0.013).

Applicability:

While the study was not conducted in the UK, the evidence is directly applicable to people in the UK. There are no obvious differences in the population, context or setting of the study.

[1] Brown and Herman 2005 (-)

Evidence Statement 3.7: Mass Media Campaigns Targeting Adults

There is weak evidence from one pre-post study (+)¹ and one non-RCT (-)² that mass media campaigns may lead to minor short-term improvements in food safety knowledge and some short-term changes in food safety behaviour.

One pre-post study¹ (+) (USA; n=250) found that the mass media Fight BAC! Campaign, targeting the Latino community, was effective at improving food safety knowledge among participants who had seen the campaign compared with those who had not seen the campaign (aOR 3.54 [95%CI: 1.74 to 7.18]). However, the campaign only had a significant effect on two of nine food safety behaviour practices: proper hand washing increased from 94% to 99% (p=0.04) and proper meat defrosting technique increased from 7% to 14% (p=0.01).

One non-RCT² (-) (UK; n=38) found that a UK-based mass media intervention designed to improve safety behaviour during food preparation had some immediate effectiveness on observed food safety behaviour that was not sustained 4 to 6 weeks later. Overall the mean score for food safety malpractice score among controls ranged from 9,501 to 9,845 (scoring scale not reported) over the course of the study. For the intervention group, the mean score decreased from 12,373 to 7,322 immediately after intervention, but increased to 9,835 after a period of 4 to 6 weeks (p-values were not reported). In the intervention group, the immediate intervention effect upon all targeted behaviours was either "low" or "moderate" (effect sizes ranging from 0.18 to 0.47) (p-values were not reported).

Applicability:

The evidence is only partially applicable to the wider UK population, as the studies populations may differ from the wider population of the UK, although for the US study the interventions could be conducted in the UK context and the results are likely to be relevant to other ethnic minority groups.

[1] Dharod et al. 2004 (+)

[2] Redmond et al. 2006 (-)

Evidence Statement 3.8: Computer-Based Interventions Targeting Adults

There is weak evidence from one RCT (+)¹ and one pre-post study (-)², that education delivered via a computer, with or without printed materials, may improve food safety knowledge but not food safety behaviours.

One RCT¹ (+) (USA; n=446) found that neither web-based nor printed materials significantly improved adherence to any of the 10 food safety practices tested (p>0.05 for all) or intention to consume any of the 12 risky food groups (p>0.05 for all) among older adults (aged 70 to 75 years old). However, many appropriate practices, such as storing leftovers for no more than five days and refrigerating leftovers within two hours, were already high at baseline (89.8% and 94.0%, respectively).

One pre-post study² (-) (Sweden; n=92) found that a computer-based education programme significantly increased knowledge of food safety in adults immediately following the intervention related to cross-contamination (52% vs 87% (p0.001)) and knowledge of the correct storage temperature for smoked salmon and raw mincemeat (22% vs 67% (p0.001) and 23% vs 67% (p0.001), respectively). However, there was no significant improvement in food safety behaviours; the proportion of participants refraining from tasting raw mincemeat non-significantly increased, from 80% before to 88% (p=ns) three weeks after, while the proportion checking the fridge temperature non-significantly decreased, from 51% to 41% (p-values were not reported).

Applicability:

The evidence is directly applicable to people in the UK. There are no obvious differences in the population, context or setting of the study compared with the UK context.

[1] Kosa et al. 2011 (+)

[2] Nydahl et al. 2012 (-)

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The research described in this article was prepared for the National Institute for Health and Care Excellence (NICE) and conducted by RAND Europe.