Behavior Changes: Role of Higher Education Institutes in Combating AMR

Abstract The discovery of antimicrobial drugs in the mid twentieth century revolutionized the treatment of infections in humans and animals. They are responsible for saving uncountable lives since their discovery by declining the mortality and morbidity due to infectious illnesses. However, the emergence of microorganisms resistant to antimicrobials is now posing a grave universal public health threat [i]. Antimicrobial resistance (AMR) is a multifarious and complex problem affecting humans, animals, plants and the environment[ii]. It has considerable impact at local, national and global level. As per WHO 2019 report, approximately seven lakh people die per year as a result of drug-resistant illnesses. Every year in the United States, about twenty eight lakh humans get an antibiotic resistant contagion; however, greater than thirty five thousand succumb lives as a result of it [iii]. Resistant infections often require treatment with more toxic, costly drugs and with extended hospitalization. Resistant infections also have an outcome on animal health ensuing challenges in effective disease prevention and treatment choices[iv]. Antimicrobial resistance is an occurrence which happens when microbes have a greater probability to stay alive and reproduce on exposure to usual anti-infective drugs. The important factors of AMR include the inappropriate usage of antibiotics, the transmission of healthcare associated infections to communities, non compliance to infection prevention and control procedures within health care agencies, microbial spread between animals and human beings via the food chain and environmental factors such as disposal of waste water from homes, hospital, manufacturing, or farm animals sites[v], [vi],[vii] . There are many factors responsible for development of antimicrobial resistance. Four main areas are implicated in the evolution of antibiotic resistance: mankind treatment, animal production and agriculture, and the environmental section. The insufficient knowledge regarding action, correct dosing, adverse effects and concept of antibiotics as “wonder drugs” for any ailment leads to inappropriate and excessive usage among people which is facilitated by easy purchasibility even without any prescription. Use of antimicrobials for promoting growth, disease prevention & treatment amongst food-producing animals and aquaculture is also a sizable contributor in the development of AMR[viii] (Marshall, 2011). Considering the emerging reality of AMR, there is an urgent need for action to overcome the developing worldwide crisis. Because human, animal and environmental heaths are connected, it is essential to consider the emergence and spread of AMR from a One Health perspective. One Health is the joint effort of several disciplines and sectors recognizing the interconnection between people, animals, plants and our shared environment in the development of AMR 4(CDC, 2019). Keeping in consideration the magnitude of the AMR and the impending awful outcomes on wellbeing & economy, the World Health Assembly (WHA) adopted the “Global Action Plan (GAP)” in 2015 [ix](WHO, 2017).  Subsequently, various nations then developed their own National action plans (NAPs). The “Ministry of Health and Family Welfare,” India also published its “National Action Plan” in April 2017. This five year NAP (2017–2021) highlights the main concerns and execution approaches for AMR control in India (NAP-AMR, 2019). In the year 2016, various pharmaceutical, biotechnology and diagnostics industries signed “Davos Declaration” on combating antimicrobial resistance[x] (AMR Industry Declaration, 2016). Prevention and control of AMR is a multifarious, multi-stage process and requires a wide range of community partnerships and expertise beyond the traditional partners in public health. There is a need to engage a variety of key stakeholders to control, contain and mitigate the AMR. Higher education institutes (HEIs), the centers of creativity and innovation can serve an important role to influence the health and wellbeing of communities. HEIs are also a valuable community treasure with roles in education, training and research. They possess intellectual & skilled expertise, the authority and the trustworthiness in developing, testing and disseminating knowledge, skills & sustainable innovative solutions to facilitate behavior change amongst target audience. The accomplishment of the health promoting movement relies on the ability of HEIs to integrate a commitment to health within the policies and procedures. There is an unmet need to change the key drivers of AMR like erroneous culture of demand, availability, prescription and use of antimicrobials. Behavioural modifications through improved awareness & sustainable solutions are a global public health priority against Antimicrobials resistance (AMR). The designing and evaluation of behaviour change interventions should incorporate the use of appropriate theory. [xi], [xii]( Glanz & Bishop, 2010; Noar, Benac, & Harris, 2007). Different educational initiatives could actually reduce the antibiotics prescription and  usage. Educational programs such as seminars[xiii] (Corvoisier et al, 2013), campaigns[xiv],[xv] (Santis et al, 1994; Monette et al, 2007), focused group education using evidence-based medicine and communication skills[xvi], [xvii] (Cals et al, 2009, Finkelstein  et al, 2001), educational outstation camps[xviii],[xix] (Welschen et al, 2004; Altiner et al,2007), flyer or leaflets  and a combination of any of these strategies[xx] (Enriquez-Puga et al, 2009)  are very effective and lead to reduction of 30-40% in usage of antibiotics. Along with usage, the prescription of antibiotics is also found to be reduced as an impact of educational programs. Besides awareness programs, other strategies like feedbacks, audits, decisive support system, clinical reminders, and financial and regulatory incentives were also been utilized as behavioural change programs. The mixed intervention programs are more effective in comparison with single program and found to be effectual for patient education[xxi], [xxii](Doyne et al 2004; Francis et al, 2009), delayed prescriptions [xxiii](Macfarlane et al, 1997) and decision support system[xxiv] (Metlay et al, 2007). Combined/ mixed interventions are more effective in reducing the antibiotics prescription than the single intervention using educational measures only.             Few studies were identified in countries such as France, England and Czech Republic where  innovative educational programs like  “e-Bug teaching pack” were implemented among school children and  found  to be  effective[xxv]. Advisory Committee on “Antimicrobial Resistance and Healthcare-Associated Infection” (ARHAI) Education sub-Group agreed to an antimicrobial campaign in which posters were prepared helping public understand on how to handle an ailment like cold. Physicians are also being encouraged to share information with public on expected course of symptoms, self care, benefits and hazards of antibiotics usage. The “General Medical Council” in 2009 requested all HEIs’ Deans to make certain that prevention and control of contagion and prescription of antimicrobials should be taught in clinical settings to both undergraduate and postgraduate medical students[xxvi] (McNulty, Cookson & Lewis, 2012). HEIs can take up the responsibility of creating awareness among target audiences through different traditional and innovative tools. There are numerous strategies which can be employed by the HEIs to contribute towards prevention and control of AMR. Strategies towards promotion of behavioral modifications, development of innovative solutions and policies are a few that can help in achieving the goal. The priority audience for such strategies includes Public, Health care prescribers, Pharmacists and policy makers. To educate prescribers and public about prudent use of antibiotics, interventions based on their educational level needs to be developed and implemented. Till now most of the educational efforts were targeted to medical professionals and its success has reinforced the idea that educational programs to reduce antibiotic use should be prepared for other groups as well. It is crucial to develop appropriate curricula for teaching medical and nonmedical undergraduate students about microbial virulence, general medicine, antibiotic resistance, and cautious antibiotic prescribing[xxvii] ( Lee et al, 2015). The following article discusses the impact of AMR, importance of Behavior change and Role of Higher educational institutions in developing, testing and disseminating knowledge, innovative solutions to facilitate behavior change amongst target audience.