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The drugs don't work: evaluation of educational theatre to gauge and influence public opinion on antimicrobial resistance

Open AccessPublished:October 16, 2019DOI:https://doi.org/10.1016/j.jhin.2019.10.011

      SUMMARY

      Increased public awareness of antimicrobial resistance (AMR) is a key component of effective antimicrobial stewardship strategies. Educational theatre combined with an expert panel was used to engage the public about AMR through delivery of a play entitled ‘The drugs don't work’. Audience knowledge and understanding of AMR were measured by pre- and post-play questionnaires. Performance of the play and discussion with the expert panel significantly improved audience knowledge and understanding of AMR, including antibiotic misuse and prescribing. Educational theatre provides a positive learning experience and is an innovative method of public engagement to disseminate important public health messages.

      Keywords

      Introduction

      Antimicrobial resistance (AMR) is a global problem in the 21st Century. Equipping the public with a better comprehension of AMR, correct antibiotic use and problems associated with antibiotic misuse – for example, how and when to take antibiotics – could play an important role in effective antimicrobial stewardship [
      National Institute for Health and Care Excellence
      Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use.
      ,
      • McCullough A.R.
      • Parekh S.
      • Rathbone J.
      • Del Mar C.B.
      • Hoffman T.C.
      A systematic review of the public's knowledge and beliefs about antibiotic resistance.
      ,
      • Gualano M.R.
      • Gili R.
      • Scaioli G.
      • Bert F.
      • Siliquini R.
      General population's knowledge and attitudes about antibiotics: a systematic review and meta-analysis.
      ]. Antibiotic awareness campaigns conducted at national, European and global levels have promoted better public awareness of AMR through communication using factsheets, posters, videos, social media and interactive games. The ‘active ingredients’ of interventions targeting the public's engagement with AMR and how they might work have been analysed by McParland et al. [
      • McParland J.L.
      • Williams L.
      • Gozdzielewska L.
      • Young M.
      • Smith F.
      • MacDonald D.
      • et al.
      What are the 'active ingredients' of interventions targeting the public's engagement with antimicrobial resistance and how might they work?.
      ]. They reported that only 15% of behaviour change techniques have been applied in AMR interventions, thus providing a clear opportunity for the development of novel interventions in this context. Theatre performance is an alternative educational campaign for increasing public awareness of health issues such as human immunodeficiency virus/acquired immunodeficiency syndrome [
      • Glik D.
      • Nowak G.
      • Valente T.
      • Sapsis K.
      • Martin C.
      Youth performing arts entertainment-education for HIV/AIDS prevention and health promotion: practice and research.
      ] and smoking [
      • Perry C.L.
      • Komro K.A.
      • Dudovitz B.
      • Veblen-Mortenson S.
      • Jeddeloh R.
      • Koele R.
      • et al.
      An evaluation of a theatre production to encourage non-smoking among elementary age children: 2 Smart 2 Smoke.
      ]. This study explored the value of this approach to increase public awareness of AMR. A three-act play entitled ‘The drugs don't work’ was written to highlight important issues surrounding antibiotics and the consequences of their misuse. The three acts covered the public's unrealistic expectations of antibiotics, misuse and misconceptions of the efficacy of antibiotics, and the consequences and impact of resistance. Issues raised in the play were discussed through dialogue between an expert panel and the audience between each act. The objectives of the study were to assess the knowledge and understanding of AMR of members of the general public, and the impact of educational theatre combined with an expert panel on raising awareness of this global issue.

      Methods

      The play was written, produced and presented in collaboration with the Hobgoblin Theatre Company, a national touring theatre company specializing in the provision of original educational theatre (visit http://www.hobgoblintheatrecompany.co.uk). The script was developed with reference to the Antibiotics-e-Bug young adult educational resource documents for 15–18-year-old students following UK key stages 4 and 5 in science relating to AMR []. The play presented a fictional scenario in which a pop music singer developed a sore throat before a live performance. In the first act, she sought, and subsequently received, a course of antibiotics as treatment. This first act illustrated the issues surrounding the unrealistic expectations and public demand for antibiotics for treatment of a respiratory infection most likely to be of viral origin. The second act investigated attitudes towards the correct use of antibiotics. After a successful performance, the character felt better and decided not to continue with the course of antibiotics. The final act explored the possible consequences of unnecessary use and poor compliance on the use of antibiotics. One year after the sore throat incident, while on a world tour, the character acquired a serious gastrointestinal infection that failed to respond to all available antibiotics. This raised key questions on antibiotic resistance concerning what or who was responsible. Was the outcome the direct result of the character's demand for antibiotics to treat a trivial infection and her failure to follow instructions on their use? These issues were explored with the audience through discussion with members of an expert panel between each act and following the presentation of the play. The panel comprised clinical and medical microbiologists, pharmacists, biochemical engineers and social scientists.
      The play was presented on three separate occasions: to school and family audiences at two workshops held at the Birmingham Think Tank Science Museum in April 2017, and to a mainly adult audience at the Cheltenham Science Festival in June 2017. The Think Tank is an award-winning science museum located in Birmingham, UK which houses a wide array of interactive science exhibits and historical collections (https://www.birminghammuseums.org.uk/thinktank). Located within the museum complex is a theatre which hosts a variety of educational theatre and interactive science events. The Cheltenham Science Festival is an annual 5-day event held in Cheltenham, UK which incorporates a wide range of interactive science and engineering activities (https://www.cheltenhamfestivals.com/science). Audience knowledge, attitudes and opinions on AMR were recorded using paper questionnaires before and after the play. The pre- and post-event questionnaires were assigned with a unique code identifier to ensure that pre- and post-event questionnaires were correctly aligned to the participating individual. The pre-event questionnaire was issued to all individuals upon entry to the events and collected, with responses, prior to commencement of the play. Post-event questionnaires were issued following the performances. The questionnaires were collected following audience responses and aligned to the pre-event responses based on the unique participant code identifier.
      The audience members scored their responses to Questions 1–8 before and after the performance of the play using a Likert scale (1 = ‘strongly disagree’ and 5 = ‘strongly agree’). The non-parametric Wilcoxon matched-pairs test was used to compare the Likert scores for pre- and post-performance responses for each question, and both direction and magnitude of change were taken into account (GraphPad Prism Version 7.00 for Windows, GraphPad Software, La Jolla, CA, USA).
      Two links to ‘The drugs don't work – a tale of resistance’, and a copy of the script, are provided as online supplementary material.

      Results

      The Cheltenham Science Festival presentation was attended by 105 people (mean age 47 years, range 17–94 years), whilst the combined Think Tank presentation was attended by 137 people (mean age 23 years, range 6–67 years). Table I presents a summary of audience knowledge, attitudes and opinions on AMR obtained using self-administered questionnaires before and after the play.
      Table IQuestions posed to the audience pre- and post-performance of the play
      Question
      1I know a lot about microbiology and antibiotics
      2Antimicrobial resistance is a very serious problem
      3My GP can establish if a sore throat is bacterial or viral
      4When I am suffering from a sore throat and seek medical attention, I should expect my GP to give antibiotic medication
      5When I am suffering from a sore throat and seek medical attention, if my GP does not prescribe antibiotic medication, they are not doing their job
      6Even if I feel better, I will complete a full course of antibiotics
      7I only use antibiotics prescribed to me
      8I never use antibiotics left over from a previous prescription
      GP, general practitioner.
      Mean self-assessed responses to the eight questions asked pre- and post-performance of the play by the Cheltenham and combined Think Tank audiences are shown in Figure 1. Significantly altered scores for Questions 1, 2, 3, 4 and 7 (P<0.05) were recorded for both audiences after presentation of the play. Significant changes in scores for Questions 5, 6 and 8 were apparent only in the Think Tank audiences. This difference in audience response most likely reflects the mean scores for the Science Festival audience that were low for Question 5 and high for Questions 6 and 8 before performance of the play, allowing little scope for significant change. Scores for Questions 1 and 2 indicate that the play had a positive effect on increasing knowledge in the areas of microbiology and antibiotics, and awareness of the importance of AMR for all audiences. Scores for Question 3 indicate that the play improved appreciation of the lack of tests available to distinguish between viral and bacterial throat infections in primary care. Whilst rapid tests for bacterial infection of the throat (e.g. group A streptococcus) are available, they are not recommended in the National Institute for Health and Care Excellence (NICE) guidelines and are unlikely to be a cost-effective use of National Health Service resources [
      National Institute for Health and Care Excellence
      Rapid tests for group A streptococcal infections in people with a sore throat.
      ].
      Figure 1
      Figure 1Mean self-assessed scores for each question pre- and post-performance of the play. Mean Likert scores (1 = ‘strongly disagree’ and 5 = ‘strongly agree’) are shown with standard deviation as bars for the Cheltenham Science Festival audience (filled circles) and the combined Think Tank audiences (filled squares). The significance of the differences in self-assessed scores for each question pre- and post-performance of the play was determined by calculation of exact P-values by Wilcoxon matched-pairs tests of all the self-assessed scores for the questions, including those that did not change.
      The play also lowered audience expectations of receiving antibiotics for a sore throat from their general practitioner (decreased scores for Question 4 after performance of the play). Questions 6, 7 and 8 suggest that attitudes and behaviours of the audience members towards the use of antibiotics were appropriate before the play.

      Discussion

      The AMR play provided a novel platform to gauge the level of knowledge, attitudes and behaviours of the audience towards the use of antibiotics. The mean responses to items on the pre- and post-event questionnaires demonstrated an overall change in the scores following presentation of the play. These mean values include responses from audience members whose views did not change after presentation. The significance of the changes was determined by analysis of those audience members whose responses did change. The members of the Think Tank audiences significantly changed their responses to all of the questions. The Think Tank audiences comprised a majority of students (87/137) in the key stage 4 age group, whose attitudes were clearly influenced by the play. In contrast, the Cheltenham audience comprised a majority of adults (97/105). Members of this audience whose responses changed following presentation of the play showed significant changes to Questions 1, 2, 3, 4 and 7 but not to Questions 5, 6 and 8. This observation supports the targeting of information on AMR issues to young adults under key stages 4 and 5 as part of the personal, social and health education curriculum and through initiatives such as e-Bug [].
      Using a range of formats to engage the public is central to promoting important healthcare messages. The Antibiotic Guardian campaign launched by Public Health England in 2014 included an online pledge system to increase commitment from healthcare professionals and members of the public to reduce AMR. Almost half (45.5%) of those who participated in the campaign reported an increase in knowledge about AMR following the campaign. Similarly, the Wellcome Trust Monitor report, based on a UK public opinion poll, showed that whilst 56% of respondents considered their knowledge to be good, 33% believed that antibiotic resistance referred to the human body becoming resistant to antibiotics, rather than antibiotic-resistant micro-organisms [
      • Brookes-Howell L.G.
      • Elwyn K.
      • Hood F.
      • Wood F.
      • Cooper L.
      • Goossens H.
      ‘The body gets used to them’: patients’ interpretations of antibiotic resistance and the implications for containment strategies.
      ]. Furthermore, whilst 41% of respondents understood that antibiotics only work against bacteria, 38% suggested that they acted against viral infections and 21% against fungal infections. Thus, there is a need for educational initiatives to improve public understanding of the specific use of antibiotics and AMR.
      The findings from this study demonstrate, in line with previous studies, that there is a general lack of awareness, understanding and knowledge within the general public regarding the use and misuse of antibiotics. This study also demonstrated that the use of innovative and ‘enjoyable’ platforms such as educational theatre, supported by an expert panel, significantly raises awareness of key public health issues post event. It may be that the general public are more likely to engage with key health issues if they are presented in an engaging way and in an environment that is accessible to all age groups and backgrounds. In more traditional public health interventions, the key messages are typically ‘pushed’ on to the audience, whereas in the interactive play format, the issues are presented and the audience invited to question their understanding. In this way, the key messages are ‘pulled’ from the audience, giving them a greater sense of ownership, involvement and engagement with the issue.
      AMR reflects a very contemporary topic for a range of science and healthcare practitioners, and there is an urgency to explore and identify effective strategies to influence public knowledge, attitudes and behaviours. Antibiotic Guardian campaigns have sought to increase commitment from healthcare professionals and members of the public to reduce AMR [
      • Cox J.A.G.
      • Worthington T.
      The 'antibiotic apocalypse' – scaremongering or scientific reporting?.
      ], and whilst the importance of AMR campaigns is undisputed, little is known about the most effective mechanisms to influence knowledge, attitudes and behaviours. Therefore, exploring how to generate impactful campaigns for different audiences presents a valuable opportunity to conduct multi-disciplinary and multi-modal research. The work described in this paper demonstrates such an initiative, and it is also likely that greater attention to the process of influencing knowledge and attitudes may help us to better understand how, why and for whom educational approaches are particularly effective. Individuals learn differently and employing a range of strategies to influence personal knowledge acquisition that goes beyond simply reading or hearing information is vital.
      In conclusion, this study demonstrated that educational theatre in conjunction with an expert panel is a simple, innovative tool which positively impacts upon individual knowledge, understanding and attitudes towards AMR. While this study focused on AMR, the authors believe that use of this platform for raising awareness of other key public health issues is a significant step in the right direction. However, it is beyond the scope of this study to ascertain if this shift in knowledge and understanding is retained over time, and whether it has an impact upon individual behaviours post event.

      Ethical approval and consent to participate

      An application was submitted to the University Research & Ethics Committee and considered by the Life & Health Sciences Ethics Committee under Application #1107. As an evaluation of a public engagement event, the requirement for ethical approval was waived by the Chair of the LHS Committee.

      Conflict of interest statement

      None declared.

      Funding source

      The work was supported by the UK Engineering and Physical Sciences Research Council : Bridging the Gaps between Engineering and Physical Sciences in Antimicrobial Resistance as part of the UK Cross-Research Council Initiative on Antimicrobial Resistance Grant No. EP/M02735X/1 .

      Appendix A. Supplementary data

      The following is the supplementary data to this article:

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