POLICY BRIEF

Supporting education on AMR for the public and medical
practitioners
Executive summary• Understanding about antimicrobial resistance remains highly variable across countries, and awareness and education has beena primary strategy for many National Action Plans on AMR.
• In Japan, awareness among the public and healthcare workers remains low. Many organizations have been actively working
toward raising awareness, such as the AMR Clinical Reference Center.
• While international, national, and multi-sectoral organizations have been implementing awareness activities and supporting
educational programs, the impact of such programs has been inconsistent across countries.
• Evidence-based and context-specific educational programs are need to raise awareness on AMR among the public andhealthcare workers.

Introduction
The first objective of the leading policy report to curb antimicrobial resistance, Global Action Plan on Antimicrobial
Resistance published by the Food and Agriculture Organization, World Organization on Animal Health, and World HealthOrganization is to “improve awareness and understanding of antimicrobial resistance through effective communication,
education, and training.”1 Awareness-raising and educational measures are crucial to efforts to change behavior in order totackle antimicrobial resistance. Such activities are not restricted to the general public, but also target healthcare professionals,
such as doctors, nurses, pharmacists, and medical technicians. That said, the positive impact of public awareness campaigns
cannot be guaranteed. Awareness-raising and educational efforts are challenging due to the need for messages to be based on
scientific evidence and tailored to local contexts. 2,3
Public awareness on antimicrobial resistance focuses on the promotion of proper antimicrobial consumption and the call for
public action on AMR. Uninformed about antimicrobial resistance, patients may ask for antimicrobials when they’re ineffective.
Examples of public education on AMR include social media (e.g. Twitter, Facebook, and Instagram), outreach material, school
activities, and media seminars.
Education for medical professional’s centers around antimicrobial stewardship and ensuring that countermeasures are taken
to limit the spread of antimicrobial resistance. To ease the fear of patients, doctors may prescribe antimicrobials even if they are
ineffective. Moreover, doctors may prescribe the wrong antimicrobial regimen, exacerbating antimicrobial resistance. Examplesof education for healthcare professionals on antimicrobial resistance include educational seminars by antimicrobial stewardshipteams (ASTs) and infection control teams (ICTs), clinical guidelines, and monitoring of antimicrobial prescription patterns.

Background of the Issue: Japan
According to a 2019 internet survey by Health and Global Policy Institute, 38.6% of the general public in Japan is unaware of
AMR as a concept.4 Even among the 61.5% of people that know of AMR, 47.3% reported having only heard of the term, withlittle understand about what it means. Such major gaps in awareness can result in misunderstandings surrounding the causes of
AMR and unnecessary requests from patients to prescribe antimicrobials when they are sick.
For example, the HGPI survey found that 51.2% of the general public is unaware that antimicrobials are ineffective for
influenza. 4 As a consequence, doctors have indicated that they feel pressured by patients to prescribe antimicrobials forconditions that do not require them, which can accelerate antimicrobial resistance. In Japan, among physicians that haveprescribed antimicrobials for the common cold, about 28% claim it was due to demands from patients or their family. 5
Lack of awareness surrounding AMR is not limited to the general public, but is also seen among doctors. In Japan, theMinistry of Health, Labour, and Welfare published the “Manual of Antimicrobial Stewardship,” which provides guidelines forphysicians when prescribing antimicrobials. 6 However, according to a 2019 survey by The Japan Association for Infectious
Diseases, only 14.2% of clinical doctors used the manual, while 85.9% of physicians either knew about it but did not use it (43.7%)
or were unaware of it (42.2%).5 Despite the low uptake, about 61% of physicians believed that manuals and guidelines areneeded for daily practice. Furthermore, at the policy level, about 44.9% of physicians are unaware and only 32.2% have heard ofJapan’s 2016 National Action Plan on AMR, the report on Japan’s strategy for curbing AMR. 5

Stakeholders and Countermeasures: Japan
Stakeholder
Cabinet Secretariat

Ministry of Health, Labour, andWelfareCountermeasure• “Antimicrobial Resistance (AMR) Countermeasure Promotion Month” 7• “AMR countermeasure, dissemination, and awareness” awards.
• Public awareness raising meeting on promoting measures against AMR• “Reduce AMR!” Ambassador”• Manual for Antimicrobial Stewardship

AMR Clinical Reference Center• Regular online surveys to Japanese public on the appropriate use of antimicrobials. 8• Targeted public education and awareness-raising activates for parents with young children• Website – easily accessible information on AMR and infectious diseases in general• Outreach material – nine videos, nine posters, four leaflets, three booklets, and seven infographics
freely available to download• Other activities include media seminars, activities in schools, Infectious Disease Education
Consortium, and National Conference on Drug Resistance Promotion (AMR) Measures.

Mie Prefecture’s AMR awarenessprogram• During the AMR awareness month in November 2017 and 2018, leaflets and posters about open
lectures and events were distributed to all hospitals, healthcare facilities for the elderly, and healthinsurance pharmacies in Mie Prefecture. Billboards and advertisements were also set up in bus andTsu railway station. 9

News and Media• Coverage of AMR on television, radio, and newspapers. Dissemination of information fromacademics and credible sources, such as AMR Clinical Reference Center.

Antimicrobial Stewardship Teams(ASTs) and Infection Control
Teams (ICTs)• Education programs - monitoring and feedback, optimization of antimicrobial drugs such as deescalation, and revision of guidelines and clinical pathway. 10

Background of the Issue: Global
While many countries have implemented educational campaigns, their impact has been sparse, and awareness varies acrosscountries and populations. In 2015, a public survey conducted by the World Health Organization (WHO) across 12 countries
found that the percent of people who have heard of the term “antibiotic resistance” ranged from 22% in Egypt to 89% in
Mexico. 11
Among high-income countries, a number of research reports have found low level of adult public understanding regarding
antimicrobial resistance. In Italy, only 9.8% of the general population knew the definition of antimicrobial resistance and only
21.2% knew when it was appropriate to use antibiotics.12 In England, 35% of adults wrongly believed that antibiotics kill viruses
or treat viral infections.13 However, awareness does differ across high-income countries. In Sweden awareness is higher, as 80.9%
did not agree that antibiotics cure common colds more quickly.14 The reasons for why AMR awareness remains highly variable
across high-income countries remains unclear.
Physician awareness surrounding antimicrobial resistance and antimicrobial stewardship remains inadequate, and unnecessary
prescription of antimicrobials continues to be high. In the US, a survey of fourth-year medical students at three medical schools(University of Miami, John Hopkins University, and University of Washington) showed that a majority of students did not know theappropriate management of antimicrobial-resistant infections.15 However, awareness does vary across high-income countries, as
physicians in Canada demonstrated high levels of AMR stewardship and knowledge on antibiotics. 16
Raising awareness about AMR in low- and middle-income countries is critical since healthcare systems may be ill-equipped todeal with outbreaks. A cross-sectional survey in Pakistan found that 41% of participants used left over antibiotics from their own
or someone else’s previous antibiotic course. 17 Also, the effects of AMR awareness campaign in low- and middle-income
countries have been mixed, raising questions about what are the best strategies for spreading awareness. A study implementing
educational activities in two Lao villages indicated that activity-related communication circulated more among privileged groups
and effects on attitude were minor. 18

Stakeholders and Countermeasures: Global
Stakeholder

Countermeasure

World Health Organization• World Health Organizations - the World Antibiotic Awareness Week in November since 2015. 19

European Union• e-bug program - online website with games and teaching resources about microbes and antibiotics
for the general public. 20

Irish Department of Health• “Action on Antibiotics” campaign to change antibiotic prescribing and spread awareness on new
guidelines for antimicrobial stewardship. However, adherence to antibiotic prescribing guidelines
remains highly variable. 21

ReAct• ReAct supports antimicrobial awareness activities through its global branches – Africa, Asia Pacific,
Europe, North America, and Latin America. Examples include raising awareness in primary school
children in Kenya and workshops for the Indian Dental Association.
• Reimagining Resistance – project aiming to challenge the idea of bacteria as mere causes of disease,and promote a more ecological and holistic approach to antimicrobial resistance. Bridges art andmedicine to challenge our perceptions on AMR. 22• Toolbox – online website with information and practical guidelines for raising awareness on AMR

The Antimicrobial ResistanceFighter Coalition• A multi-sector coalition between government agencies, healthcare professionals, patients andfamilies. The campaign collects and shares personal stories and firsthand experiences fromhealthcare and public health professionals, as well as survivors of antimicrobial resistanceinfections. 23

Wellcome Trust/DBT Indian
Alliance, World Comics India,
Centre for Cellular and Molecular
Biology• “Superheroes Against Superbugs” program - During this multiday program, children took part in aninteractive workshop on microbes, infections and antibiotics, building into conversations on
antimicrobial resistance. The children were also encouraged to transform their own stories about
antimicrobial resistance into comics and animation. The success of this program clearly demonstrates
the strength of a multi-sectoral approach and the importance of raising awareness even for children,
who will shape the future. 24

AMR Alliance Japan Recommendations• The Government should work to increase the opportunities that the general public has to learn about AMR. The Government
should consider how to appropriately support informational initiatives tailored to different audiences, such as the elderly or
the young, through a variety of media sources, including newspapers, magazines, television, social media, and the internet.
The Government should construct a cooperative system among school doctors, school pharmacists, and school nurses at
educational and childcare institutions, and work to increase opportunities to accurately and actively promote information on
infectious disease prevention, including information related to AMR and vaccines• The Government should increase the opportunities the public has to learn about the spread of infectious diseases and how
they can be prevented by vaccines, disinfection practices, and so on.
• The Government should promote the further training of medical practitioners with specialized knowledge in infectious diseases(licensed specialists) that can contribute to AMR countermeasures.
• Growth in the number of medical personnel trained in therapeutic drug monitoring (TDM) and the expansion of the use of
TDM for antimicrobials would help to further facilitate decisions about the appropriateness of antimicrobial use and hence,
AMR countermeasures. The Government should consider supporting training and the expansion of TDM practices to more
antimicrobials through revisions to the medical fee system.
• The Government should make use of the Conference on Public Awareness-raising for AMR Countermeasures and otherfora to promote multi-stakeholder collaborations among medical personnel, patient advocates, insurance payers, industry,
the Government, and experts on AMR, in order to reinforce current AMR educational activities. The Government should
promote the creation of opportunities for community doctor associations, pharmacist associations, health centers and so on tocollaborate for the promotion of awareness-raising in their communities.

References
1. The Food and Agriculture Organization, World Organization on Animal Health, World Health Organization. “Global Action Plan on Antimicrobial
Resistance” (2015)
2. Huttner, Benedikt, Mirko Saam, Lorenzo Moja, Karen Mah, Marc Sprenger, Stephan Harbarth, and Nicola Magrini. "How to improve antibiotic
awareness campaigns: findings of a WHO global survey." BMJ global health 4, no. 3 (2019): e001239.
3. McNulty, Cliodna AM, Tom Nichols, Paul J. Boyle, Mark Woodhead, and Peter Davey. "The English antibiotic awareness campaigns: did theychange the public's knowledge of and attitudes to antibiotic use?." Journal of Antimicrobial Chemotherapy 65, no. 7 (2010): 1526-1533.
4. Health and Global Policy Institute. “2019 Survey on Healthcare in Japan” (Tokyo, Japan, 2019)
5. Gu, Yoshiaki, Yumiko Fujitomo, Hiroshi Soeda, Chikara Nakahama, Naoki Hasegawa, Shigefumi Maesaki, Masayuki Maeda, Tetsuya Matsumoto,
Isao Miyairi, and Norio Ohmagari. "A nationwide questionnaire survey of clinic doctors on antimicrobial stewardship in Japan." Journal of Infection
and Chemotherapy 26, no. 2 (2020): 149-156.

6. Ministry of Health, Labour, and Welfare. “Manual of Antimicrobial Stewardship (1st Edition)” (Tokyo, Japan, 2017)
7. Manabu Hasegawa. “Public Awareness Raising Activities” (Tokyo, Japan, 2017)
8. AMR Clinical Reference Center. “Home page” (Tokyo, Japan, 2020)
9. Akie Araim, Yoshinori Takahashi, Akiko Nakamura, Masaki Tanabe. "Public Awareness and Educational Activities to Improve Knowledge andUnderstanding of Antimicrobial Resistance (AMR) in Japan." American Journal of Infection Control 47.6 (2019): S21-S22.
10. Center Hospital of the National Centre for Global Health and Medicine. “ICT and AST” (Tokyo, Japan)
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the use of antibiotics in Italy." PloS one 8, no. 12 (2013).
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England: findings from a household survey in 2017." BMJ open 9, no. 10 (2019).
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and resistance in Sweden." Journal of Antimicrobial chemotherapy 65, no. 6 (2010): 1292-1296.
15. Abbo, Lilian M., Sara E. Cosgrove, Paul S. Pottinger, Margaret Pereyra, Ronda Sinkowitz-Cochran, Arjun Srinivasan, David J. Webb, and Thomas M.
Hooton. "Medical students’ perceptions and knowledge about antimicrobial stewardship: how are we educating our future prescribers?." Clinical
Infectious Diseases 57, no. 5 (2013): 631-638.
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knowledge and counseling practices related to antibiotic use and antimicrobial resistance: Two-cycle national survey." Canadian Family Physician
63, no. 12 (2017): e526-e535.
17. Akhund, Ramsha, Fatima Jamshed, Hassam A. Jaffry, Hamza Hanif, and Sundus Fareed. "Knowledge and Attitude of General Pakistani Population
Towards Antibiotic Resistance." Cureus 11, no. 3 (2019).
18. Haenssgen, Marco J., Thipphaphone Xayavong, Nutcha Charoenboon, Penporn Warapikuptanun, and Yuzana Khine Zaw. "The consequencesof AMR education and awareness raising: outputs, outcomes, and behavioural impacts of an antibiotic-related educational activity in Lao PDR."
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19. World Health Organization. “World Antibiotic Awareness Week” (2019)20. McNulty, Cliodna AM, Donna M. Lecky, David Farrell, Patty Kostkova, Niels Adriaenssens, Tereza Koprivová Herotová, Jette Holt et al. "Overview
of e-Bug: an antibiotic and hygiene educational resource for schools." Journal of antimicrobial chemotherapy 66, no. suppl_5 (2011): v3-v12.
21. Murphy, Marion, Colin P. Bradley, and Stephen Byrne. "Antibiotic prescribing in primary care, adherence to guidelines and unnecessary
prescribing-an Irish perspective." BMC family practice 13, no. 1 (2012): 43.
22. ReACT. “About us.” (Stockholm, Sweden)
23. Antimicrobial Resistance Fighter Coalition. “Read Antimicrobial Resistance Fighter Stories” (2020)
24. WellcomeTrust/DBT Indian Alliance, World Comics India, Centre for Cellular and Molecular Biology. “Superheroes Against Superbugs Pilot
Report” (New Dheli, India, 2019)