Building health worker

awareness and capacity to

address AMR: the elements of
good practice
WHO AMR Team
Outline
• Introduction and rationale;
• Approaches to health worker capacity building – pre-service and in-
service;
• Key components of capacity – knowledge, skills and attitudes;
• An appropriate curriculum;
• Good practice and cost effectiveness;
• Conclusions.
 The irrational use of medicines, is a major driver of
antimicrobial resistance (AMR).
A variety of factors can result in the misuse or overuse of
antimicrobials in health care settings including:
• a lack of knowledge or up-to-date information on
prescription of antimicrobials,

Introductio • lack of treatment guidelines, lack of laboratory capacity

to identify the organism and its antimicrobial
n susceptibility.
• unreliable or absent surveillance data on AMR and
antimicrobial usage,
• unregulated over-the-counter sale/use and poor
antimicrobial stewardship (AMS).
• Inadequate adherence to infection prevention and
control (IPC) measures in health care facilities
 • The first objective of the WHO Global Action Plan on
Antimicrobial Resistance (GAP-AMR) calls for raising
awareness and educating and training health
workers to improve antimicrobial prescribing and
dispensing behaviours.
• The WHO Global Strategy on Human Resources for
Health: Workforce 2030 complements the GAP-AMR
Introduction by offering policy guidance options on broader
policies and approaches to optimize health worker
education and training .
• WHO plays a crucial role in collating and making
available AMR education and training resources to
support educators, decision-makers and health
policy planners to implement effective policies to
control the emergence and spread of AMR.
The role of pharmacists
The pharmacist can:
• dispense antimicrobials without a prescription;
Outpatient use of • enforce rules relevant to unauthorized dispensing;
• develop appropriate regulations, where necessary;
antibiotics is key to AMR
• use repeat prescriptions for antimicrobials;
reduction. • adjust quantity dispensed vs quantity prescribed;
Community pharmacists • manage waste (used antibiotics);
have the last contact • Use pharmacies in campaigns to promote and conduct awareness
with the patient before on the use of antimicrobials;
• Inform (pharmacist to patient) on antimicrobials, AMR and AMR-
s/he receives an related issues;
antibiotic medicine and, • Train pharmacy students and pharmacists in AMR and AMR-
thus, the pharmacist acts related issues;
as the gatekeeper. • cooperate with prescribing physicians;
• provide antibiotic stewardship in primary-care settings.
• Educate patients and encourage responsible use of antibiotics
 Learning modalities can be tailored
Pre-service (student – school/university)
• To gain the basic concepts that
underpin knowledge & awareness.
(knowledge)
• Skills based learning through
observation and performance under
supervision.(skills)
• Promote development of appropriate
attitudes for responsible stewardship
of antimicrobials through training and
observing. (attitudes)
In-service (work)
• To gain enhanced concepts that lead
to a greater depth of knowledge and
awareness of AMR.
• Skill acquisition, with a degree of
competence to carry out tasks
independently.
• To actively demonstrate appropriate
attitudes and lead by example to
ensure responsible stewardship.
 Approaches to health worker awareness and
training
• In-service training for existing workforce; can be expensive and hard to systematize.
• Pre-service curriculum for those still in training is a cost-effective and sustainable intervention
that leads to broader health system strengthening. It provides students with a critical
foundation of knowledge and skills and develops their competency to practice in the real
world.
• Effective pre-service training reduces the need for future large-scale and expensive in-service
trainings
• Curriculum can have vertical pillars for prescribers, non prescribers and public health officers
and health service managers with leadership/advocacy and policy responsibilities
• Horizontal comprising modular/submodular learning topics aligned with main AMR domains
 • Health workers are enabled to protect
antimicrobials, handling them as a scarce
and limited resource.
• Health workers do not prescribe antibiotics
for viral-only illnesses, e.g. flu and common
colds.
Goals of the
• Health workers practise regular handwashing
curriculum and other personal and environmental
hygiene measures to prevent the spread of
germs.
• Health workers follow and adhere to
evidence-based clinical guidelines when
prescribing antimicrobials.
 • The topics included and the time to be allotted should be
defined by each user or institution according to their needs (i.e.
local epidemiology and AMR burden, human and material
resources, and availability of diagnostic and therapeutic tools
etc.).

Appropriate • The expected level of effort required by educators to develop

the AMR curriculum and the learning materials can differ for
curriculums both groups. For example, at pre-service stages it is expected
that a greater input in terms of time and guidance will be
required of educators.
• The suggested assessment methods might be adapted in
several ways keeping in mind the following considerations:
local content prioritization, existing methods of assessment in
each setting, cultural factors and the number of
educators/number of students or trainees
Matrix model for
AMR curricula
 • Interactive lectures or didactive ( didactive should not be
used solely) lectures.
• Interactive small group tutorials using problem-solving
exercises/ case-based learning – encouraging the trainee to
Teaching present, analyse and discuss.
• “Flipped” classroom approach – prior to live instructional
methods events, learners obtain basic knowledge and apply what they
have learned in lectures. They receive feedback and gain in-
depth understanding of the topic from the instructor.
• By apprenticeship – as in in-service training and laboratory-
based exercises.
• Simulation and role playing for pre-service and in-service
education.
 • e-learning modules such as massive open
online courses and webinars. Evidence
suggests using digital/blended means to
deliver education/ training for antibiotics
management can be more effective than
only traditional learning, especially in’ in-
Teaching service’ settings. See Kyaw BM, Tudor Car L, van Galen LS,
van Agtmael MA , Costelloe CE, Ajuebor O et al. J Med Internet Res.
methods 2019. doi 10.2196/14984

• Project-based learning with creation of

project reports, strategic papers and critical
appraisal of literature.
 • Butler et al (2012) assessed effects of online blended education
compared to traditional education and reported that the mean cost
of the program was £2923 (~US $4559) per practice (SD £1187 [~US
$1852]); a 5.5% reduction in the cost of dispensed antibiotics in the
intervention group compared with the control group (–0.4% to
Cost 11.4%), which was equal to a reduction of £830 (~US $1295) a year
for an average intervention practice.
effectiveness • Chen et al (2014) reported total expenditure on text messages for
each health worker in the intervention group was less than 2 ¥ (US
of training $0.32);for the control group with traditional education, it cost 560 ¥
(US $89.96) per health worker, (printed materials, accommodation,
approaches and transportation costs). This amounts to a 280-fold difference per
person.
• Little et al (2013)reported that online-based communication skills
training was more cost-effective than traditional education (10%
cost reduction) if the cost of antibiotic resistance was accounted for
(€83.21 [~US $110.67] vs €92.46 [US $122.97]).
 • Support knowledge and awareness by regulation and
regular review of practice including prescription reviews.
• Empower pharmacists to intervene if prescriptions are
Good inappropriate
• Knowledge on its own is not enough! Communication
practice in techniques are essential.
capacity • Addressing patient demands for antibiotics and
counselling patients is a critical role of health workers and
building this requires behavioral understanding. Management of
patient expectation is key.
• Reaching out to and engaging the private sector is critical.
 • Strategies combined with educational interventions
that were more effective included prescription
What feedback.
• Feedback and audit as well as comparisons of
improves the behaviors with peers can help to maximize the impact
efficacy of and improve the acceptability of stewardship
interventions.
training? • Other mandatory administrative regulations such as
specific prescribing targets or displaying ranking
information of prescribing behavior of doctors are also
helpful.
 • Didactic lectures when used alone are not
effective.
• Online interventions such as sending
educational text messages only may have
Evidence on marginal effects in reducing antibiotic
what does prescription rates (Zheng, K.; Xie, Y.; Dan, L.;Mao, M.; Chen,
J.; Li, R.; Wang, X.;Hesketh, T. Antibiotics 2022,

not work 1791.https://doi.org/10.3390/antibiotics11060791

• Short-term offline sessions failed to reduce

the antibiotic prescribing rate.
• Single intervention with only brief reading
materials was not effective.
 In the UK the ‘Stemming the Tide of Antibiotic Resistance’
(STAR) programme has been developed. A randomised
controlled trial shows a reduction of 4% in overall antibiotic
prescribing in practices receiving the STAR training package
(Butler CC, Simpson SA, Dunstan F, et al 2012). STAR now
forms a central component of the Royal College of General
Practitioner’s (RCGP) multifaceted intervention known as
Good ‘TARGET’.

practice Little et al (2013) demonstrate substantial reductions in

examples antimicrobial prescribing for acute RTIs, following a
package of internet training. The training involved
communication skills development with targeted point of
care testing. Training and provision of point of care testing
accounted for as much as 46% relative reduction in
prescribing (after adjustment) and communication raining
for a 31% reduction.
Conclusions

• Addressing AMR is everyone’s business, and all heath workers have a

critical role to play; but pharmacists are ‘gatekeepers’ and can directly
work with the prescriber and the patient, so they have a special role.
• A standardized in service and pre- service curriculum is needed that is
context specific for health workers.
• Evidence on what is good practice is still emerging, but data show that
education and awareness works best when combined with other
strategies.