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Awareness campaigns not enough to stop superbug crisis in developing countries

educational activity• New research project used social science methods to explore public health problems

• The study found only a weak relationship between awareness, attitudes and behaviour around use of antibiotics.

• Researchers recommend that awareness campaigns alone are not enough to change inappropriate antibiotics use: attention should be given to other factors including family support networks.

• Literacy, access to formal health care, and social structures also influence the success of awareness-raising campaigns.

In a landmark study of health behaviours in developing countries, researchers have found that awareness campaigns alone are not enough to reduce unnecessary antibiotic use and, in fact, could risk making the superbug crisis worse.

Antimicrobial resistant superbugs are a global health crisis arising from widespread use of antibiotics and other antimicrobials in medicine, agriculture, and their leakage into the environment. Tolerance built up by this exposure is making it increasingly difficult to treat common infectious diseases and has been described as potentially “the end of modern medicine as we know it.”*

The research, published in special issues on antimicrobial resistance (AMR) in the journals Palgrave Communications and Antibiotics, involved more than 2,000 people in five villages in Thailand and Laos. It is part of an innovative project using social science methods to explore public health issues. The findings challenge conventional wisdom that massive global public awareness campaigns are one of the best tools to address the problem of drug resistance.

For the study, lead researchers Dr Marco J Haenssgen, Assistant Professor in the Department of Global Sustainable Development at the University of Warwick, and Ms Ern Nutcha Charoenboon and their team implemented half-day educational workshops and evaluated their success alongside their social consequences.

They found:

• People who participated directly in the workshops reported greater awareness of drug resistance as a concept but did not change their attitudes or behaviour in positive ways as a result.

• Key messages from the events did not circulate within the villages as a whole but only within more privileged groups, limiting the indirect benefits of the educational activities.

• Unwanted behavioural change included an increase in antibiotic uptake from formal healthcare providers.

• One participant felt so much more confident in her antibiotic knowledge after the workshop that she began selling antibiotics from her village shop.

educational activity in southern Laos

Commenting on the findings, Asst Prof Marco J Haenssgen said:

“Our research suggests that current global health policies overemphasise the positive impact of awareness campaigns as a means to tackle the superbug crisis in developing countries.

“On the face of it, the educational activity appeared successful, for example, increasing the awareness of the words “drug resistance” from 56% to 86% (+30%) among all participants, compared to an improvement from 46% to 63% (+17%) in the villages more generally.

“But the link between awareness, attitudes and behaviour was weak and should lower our expectations about awareness raising to change behaviour.

“Factors outside of health knowledge – like the support that villagers receive from their social networks – might be similarly if not more effective in promoting healthy behaviours.”

Ern Nutcha Charoenboon, Research officer and leader of the Thai research paper, added: “We all have heard about being ‘lost in translation’, but it is something easily forgotten in educational programmes or awareness-raising campaigns.

“Our project enabled us to observe the process and the outcomes of lay people translating AMR knowledge into their own concepts and practices. It turns out that we might have to redefine and approach public problems differently because mass education campaigns could create more harm than good.”

Project leader Marco J Haenssgen said: “As the field of global health is gradually developing into ‘planetary health,’ we will depend increasingly on transdisciplinary research, comprehensive evaluation methods, and the voices of local populations. Projects like ours enable us to challenge established wisdom in health policy, understand social and contextual aspects of health behaviour, and to find innovative solutions for global challenges.”

The study was part of the Antibiotics and Activity Spaces project, a study of antibiotic-related health behaviour in rural Thailand and Lao PDR, funded by the Antimicrobial Resistance Cross Council Initiative supported by the seven research councils in partnership with the Department of Health and Department for Environment Food & Rural Affairs (grant ref. ES/P00511X/1, administered by the UK Economic and Social Research Council).

• Charoenboon, N, Haenssgen, MJ, Warapikuptanun, P, Xayavong, T & Khine Zaw, Y (2019). Translating AMR: A case study of context and consequences of antibiotic-related communication in three northern Thai villages. Palgrave Communications. doi: 10.1057/s41599-019-0226-9

• Haenssgen, M. J., Xayavong, T., Charoenboon, N., Warapikuptanun, P., & Khine Zaw, Y. (2018). The consequences of AMR education and awareness raising: outputs, outcomes, and behavioural impacts of an antibiotic-related educational activity in Lao PDR. Antibiotics, 7(4), 95. doi: 10.3390/antibiotics7040095. Available at:

26 February 2019

Notes for Editors

Quote is by Professor Dame Sally Davis

Photo 1: Educational activity in northern Thailand; photo by Nutcha Charoenboon.

Photo 2: Educational activity in southern Laos; photo by Amphayvone Thepkhamkong.

The Department for Global Sustainable Development was founded in 2015 with a remit to deliver a suite of innovative degree courses which take on the challenge of engaging with the UN’s Sustainable Development Goals in a multi-disciplinary and intellectually enriching environment. The department has grown to encompass 12 undergraduate degree courses and the Institute for Global Sustainable Development which was established in 2017 to foster research that contributes to the sustainable development agenda across the global north and global south.

The Economic and Social Research Council (ESRC) is the UK's largest funder of research on the social and economic questions facing us today. It supports the development and training of the UK’s future social scientists and also funds major studies that provide the infrastructure for research. ESRC-funded research informs policymakers and practitioners and helps make businesses, voluntary bodies and other organisations more effective. The ESRC also works collaboratively with six other UK research councils and Innovate UK to fund cross-disciplinary research and innovation addressing major societal challenges. The ESRC is an independent organisation, established by Royal Charter in 1965, and funded mainly by the Government.

The CABDyN Complexity Centre at the Saïd Business School engages in research on complex systems and networks, with a particular focus on the social, economic, financial, communication and infrastructural networks that underpin most of modern life. The acronym CABDyN stands for Complex Agent-Based Dynamics Networks, and reflects some of the techniques such as complex network analysis and agent-based modelling that the Centre’s researchers typically use to understand these systems. The activities at the Saïd Business School form part of a larger research network that applies shared methods and techniques to a broad range of problems and domains. CABDyN was established in July 2003 as a research cluster spanning the University with the seed funding under the EPSRC Novel Computation Initiative, and currently brings together a truly multi-disciplinary group of researchers across Oxford, ranging from the physical, biological and computational sciences to the social, economic and political sciences.

The Centre for Tropical Medicine and Global Health (CTMGH) is a collection of research groups within the Nuffield Department of Medicine, University of Oxford, who are permanently based in Africa, Asia and Oxford. Its research ranges from clinical studies to behavioural sciences, with capacity building integral to all of its activities. The majority of the Centre’s research is conducted at three Wellcome Trust Major Overseas Programmes in Kenya, Thailand and Vietnam, as well as at the Oxford Centre for Global Health Research. The Centre for Tropical Medicine and Global Health also brings together a number of sister groups in Cambodia, the Democratic Republic of the Congo, Indonesia, Laos, Myanmar, Nepal, and Uganda, and collaborators around the world. Tackling infectious diseases, which kill many millions of people every year, is one of the greatest challenges of the 21st century. The CTMGH is researching solutions to the increasingly urgent problems these diseases cause.


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