Evaluation of an Educational Health Website on Infections and Antibiotics in England: Mixed Methods, User-Centered Approach.

BACKGROUND: e-Bug, an educational health website for teachers and students, aims to help control antibiotic resistance by educating young people about microbes, hygiene, and antibiotic resistance, reducing the incidence of infection and, therefore, the need for antibiotics. The teachers' section of the e-Bug website has not been evaluated since it was launched in 2009, and worldwide page views have been steadily decreasing since 2013. OBJECTIVE: This study aimed to apply GoodWeb, a comprehensive framework utilizing methodologies and attributes that are relevant to the digital era, to evaluate and suggest improvements to the e-Bug website. METHODS: Electronic questionnaires and face-to-face completion of task scenarios were used to assess content, ease of use, interactivity, technical adequacy, appearance, effectiveness, efficiency, and learnability of the teachers' section of the e-Bug website. RESULTS: A total of 106 teachers evaluated the e-Bug website; 97.1% (103/106) of them reported that they would use e-Bug, and 98.1% (104/106) of them reported that they would recommend it to others. Participants thought that there was a niche for e-Bug because of the way the resources fit into the national curriculum. Suggestions for improvements included changing the menu indication by highlighting the current page or deactivating links, improving home page indication, and providing a preview of resources when hovering the mouse over hyperlinks. Additional features requested by users included a search function and access to training opportunities. CONCLUSIONS: This paper reports that the GoodWeb framework was successfully applied to evaluate the e-Bug website, and therefore, it could be used to guide future website evaluations in other fields. Results from this study will be used to appraise the current quality and inform any future changes, modifications, and additions to e-Bug.

Cervical cancer screening behaviors and proximity to federally qualified health centers in South Carolina.

INTRODUCTION: Lack of participation in cervical cancer screening in underserved populations has been attributed to access to care, particularly among women in rural areas. Federally Qualified Health Centers (FQHCs) were created to address this need in medically underserved populations. This study observed proximity to three health centers in relation to cervical cancer screening rates in South Carolina. METHODS: Data were obtained from FQHC patient visits (from 3 centers) between 2007-2010 and were limited to women eligible for cervical cancer screening (n = 24,393). ArcGIS was used to geocode patients addresses and FQHC locations, and distance was calculated. Modified Poisson regression was used to estimate relative risk of obtaining cervical cancer screening within one yearor ever, stratified by residential area. RESULTS: Findings differed markedly by center and urban/rural status. At two health clinics, rural residents living the furthest away from the clinic (∼9 miles difference between quartile 4 and quartile 1) were more likely to be ever screened (RRs = 1.05 and 1.03, p-values < 0.05), while urban residents living the furthest away were less likely to be ever screened (RR = 0.85, p-value < 0.05). At the third center, only urban residents living the furthest away were more likely to be ever screened (RR = 1.02, p-value < 0.05). CONCLUSIONS: Increased travel distance significantly increased the likelihood of cervical cancer screening at two FQHC sites while significantly decreasing the likelihood of screening at the 3rd site. These findings underscore the importance of contextual and environmental factors that impact use of cervical cancer screening services.

International promotion of e-Bug, an infection prevention and control educational intervention: survey of partners across 14 countries.

BACKGROUND: Antimicrobial resistance (AMR) is a global threat to public health. e-Bug is an educational resource developed and promoted by a network of international partners. e-Bug seeks to reduce the spread of infection and use of antimicrobials in young people and the community, so helping to control AMR. This study aimed to explore how e-Bug is promoted by international partners and observe barriers to promotion, including the extent of education about antibiotics in schools. METHODS: A total of 29 e-Bug partners were invited to complete online questionnaires on (i) methods they use to promote e-Bug; and (ii) antibiotic topics covered in the national curriculum in their countries. RESULTS: Fourteen and 15 of 29 e-Bug partners across Europe and Palestine completed the promotional activities and curriculum questionnaires respectively. The most frequently reported methods of promotion included endorsement and collaboration with government and non-government sectors and involvement in national and global health awareness campaigns. Barriers to promotion included a lack of time and funding. The curriculum survey data showed variation in antibiotic education across Europe and Palestine, lack of antibiotic education for children under 11 years of age and little change in antibiotic topics included in the curriculum since 2006. CONCLUSIONS: Future and existing e-Bug partners should be encouraged to follow promotional activities reported in this paper, including ministry endorsement, educator training, international campaigns and youth programmes. We encourage all countries to increase antibiotic topics in the school curriculum across all ages.

Using debate to educate young people in schools about antibiotic use and resistance: A before and after evaluation using a questionnaire survey.

INTRODUCTION: The use of debating as an educational tool is increasing in popularity. Students who take part in debates can develop a range of skills such as confidence and communication as well as gaining a greater understanding of the topic discussed. Within this study we have evaluated an antibiotic-resistant debate kit, assessing the ability of the debate lesson to improve student knowledge and awareness around antibiotics. METHODS: The debate lesson was delivered in seven schools across South West England to 235 students aged 13-16 years. Change in student knowledge was measured using before and after knowledge questionnaires. Student and teacher feedback and suggestions for improvements for the lesson were also collected through questionnaires and interviews. RESULTS: Quantitative questionnaires found a significant improvement in knowledge for most areas covered in the debate, particularly around the use of antibiotics to treat colds and bacteria developing resistance. Teachers felt their students engaged well with the debate session and made suggestions for minor modifications that could improve the lesson. CONCLUSIONS: The results suggest that the e-Bug antibiotic resistant debate kit is able to improve knowledge in young people around antibiotics and antibiotic resistance. Furthermore, the lesson was enjoyed by students and therefore this resource should be promoted more widely to teachers and schools.

A Comprehensive Framework to Evaluate Websites: Literature Review and Development of GoodWeb.

BACKGROUND: Attention is turning toward increasing the quality of websites and quality evaluation to attract new users and retain existing users. OBJECTIVE: This scoping study aimed to review and define existing worldwide methodologies and techniques to evaluate websites and provide a framework of appropriate website attributes that could be applied to any future website evaluations. METHODS: We systematically searched electronic databases and gray literature for studies of website evaluation. The results were exported to EndNote software, duplicates were removed, and eligible studies were identified. The results have been presented in narrative form. RESULTS: A total of 69 studies met the inclusion criteria. The extracted data included type of website, aim or purpose of the study, study populations (users and experts), sample size, setting (controlled environment and remotely assessed), website attributes evaluated, process of methodology, and process of analysis. Methods of evaluation varied and included questionnaires, observed website browsing, interviews or focus groups, and Web usage analysis. Evaluations using both users and experts and controlled and remote settings are represented. Website attributes that were examined included usability or ease of use, content, design criteria, functionality, appearance, interactivity, satisfaction, and loyalty. Website evaluation methods should be tailored to the needs of specific websites and individual aims of evaluations. GoodWeb, a website evaluation guide, has been presented with a case scenario. CONCLUSIONS: This scoping study supports the open debate of defining the quality of websites, and there are numerous approaches and models to evaluate it. However, as this study provides a framework of the existing literature of website evaluation, it presents a guide of options for evaluating websites, including which attributes to analyze and options for appropriate methods.

A Practical Approach to Establishing a Practice-Based Research Network Stakeholder Engagement Infrastructure.

INTRODUCTION: While there have been several articles detailing the importance of stakeholder engagement in research broadly and in practice-based research networks (PBRNs) specifically, few of these articles offer a replicable engagement approach that is detailed enough to translate to another setting. The goal of this article is to offer a detailed example of building stakeholder engagement infrastructure that could be replicated or translated to other settings. APPROACH: We offer a review of 1 regional PBRN's approach to building a stakeholder engagement infrastructure over a 2-year period by describing engagement activities deployed across a large, regional PBRN including a needs assessment around research and training conducted in each state of the network and a centralized conference where themes from that needs assessment were leveraged to produce a stakeholder-defined research agenda and elect a steering committee. RESULTS: Products from this process include the stakeholder-defined research agenda as well as a multi-level organizational framework for assessing facilitators and barriers in a large PBRN and an example of a framework of individualized stakeholder group preferences for engagement modalities. CONCLUSIONS: This article presents a detailed timeline and replicable approach to building a stakeholder engagement infrastructure in a regional PBRN. This article details a practical process that is embedded in the lived values of practice-based research.

Young People's Knowledge of Antibiotics and Vaccinations and Increasing This Knowledge Through Gaming: Mixed-Methods Study Using e-Bug.

BACKGROUND: e-Bug, led by Public Health England, educates young people about important topics: microbes, infection prevention, and antibiotics. Body Busters and Stop the Spread are 2 new e-Bug educational games. OBJECTIVE: This study aimed to determine students' baseline knowledge, views on the games, and knowledge improvement. METHODS: Students in 5 UK educational provisions were observed playing 2 e-Bug games. Before and after knowledge and evaluation questionnaires were completed, and student focus groups were conducted. RESULTS: A total of 123 junior and 350 senior students completed the questionnaires. Vaccination baseline knowledge was high. Knowledge increased significantly about antibiotic use, appropriate sneezing behaviors, and vaccinations. In total, 26 student focus groups were conducted. Body Busters was engaging and enjoyable, whereas Stop the Spread was fast-paced and challenging but increased vaccination and health behavior intentions. CONCLUSIONS: e-Bug games are an effective learning tool for students to enhance knowledge about microbes, infection prevention, and antibiotics. Game-suggested improvements should help increase enjoyment.

A mixed methods pilot of Beat the Bugs: A community education course on hygiene, self-care and antibiotics.

Background: e-Bug is an international health education resource which support World Health Organization (WHO) public health recommendations by educating young people about microbes, hygiene and antibiotics use. The e-Bug team collaborated with Kingfisher Treasure Seekers to develop a six-session course for community groups called Beat the Bugs covering: microbes; hygiene; antibiotic use; and self-care. A pilot was used to inform further development and evaluation. Methods: Pilot courses with 9-12 adults with learning difficulties and young parents were delivered by community leaders and observed by researchers. Participants completed before and after knowledge questionnaires. Two participant focus groups and two course leader interviews explored views on the course and retention of knowledge. Results: Completed questionnaires and qualitative results showed an improvement in participant knowledge in each session; microbes and antibiotics sessions showed the greatest knowledge improvement. Self-care showed the greatest knowledge retention and participants reported behaviour change including an increase in appropriate hand-washing and tooth-brushing. Conclusion: The Beat the Bugs course is a useful intervention for communities to give individuals the knowledge and confidence to manage their own infection and change behaviour around hygiene, self-care and antibiotics. Beat the Bugs is freely available to download.

Can Gaming Increase Antibiotic Awareness in Children? A Mixed-Methods Approach.

BACKGROUND: e-Bug is a pan-European educational resource for junior and senior school children, which contains activities covering prudent antibiotic use and the spread, treatment, and prevention of infection. Teaching resources for children aged 7-15 years are complemented by a student website that hosts games and interactive activities for the children to continue their learning at home. OBJECTIVE: The aim of this study was to appraise young people's opinions of 3 antibiotic games on the e-Bug student website, exploring children's views and suggestions for improvements, and analyzing change in their knowledge around the learning outcomes covered. The 3 games selected for evaluation all contained elements and learning outcomes relating to antibiotics, the correct use of antibiotics, and bacteria and viruses. METHODS: A mixed methodological approach was undertaken, wherein 153 pupils aged 9-11 years in primary schools and summer schools in the Bristol and Gloucestershire area completed a questionnaire with antibiotic and microbe questions, before and after playing 3 e-Bug games for a total of 15 minutes. The after questionnaire also contained open-ended and Likert scale questions. In addition, 6 focus groups with 48 students and think-aloud sessions with 4 students who had all played the games were performed. RESULTS: The questionnaire data showed a significant increase in knowledge for 2 out of 7 questions (P=.01 and P<.001), whereas all questions showed a small level of increase. The two areas of significant knowledge improvement focused around the use of antibiotics for bacterial versus viral infections and ensuring the course of antibiotics is completed. Qualitative data showed that the e-Bug game "Body Busters" was the most popular, closely followed by "Doctor Doctor," and "Microbe Mania" the least popular. CONCLUSIONS: This study shows that 2 of the e-Bug antibiotic educational games are valuable. "Body Busters" effectively increased antibiotic knowledge in children and had the greatest flow and enjoyment. "Doctor Doctor" also resulted in increased knowledge, but was less enjoyable. "Microbe Mania" had neither flow nor knowledge gain and therefore needs much modification and review. The results from the qualitative part of this study will be very important to inform future modifications and improvements to the e-Bug games.

A mixed-method evaluation of peer-education workshops for school-aged children to teach about antibiotics, microbes and hygiene.

Background: Delivering health topics in schools through peer education is known to be beneficial for all students involved. In this study, we have evaluated a peer-education workshop that aims to educate primary and secondary school students on hygiene, the spread of infection and antibiotics. Methods: Four schools in south-west England, in a range of localities, took part in peer-education workshops, with students completing before, after and knowledge-retention questionnaires. Mixed-effect logistic regression and mixed-effect linear regression were used to analyse the data. Data were analysed by topic, region and peer/non-peer-educator status. Qualitative interviews and focus groups with students and educators were conducted to assess changes in participants' skills, confidence and behaviour. Results: Qualitative data indicated improvements in peer-educator skills and behaviour, including confidence, team-working and communication. There was a significant improvement in knowledge for all topics covered in the intervention, although this varied by region. In the antibiotics topic, peer-educators' knowledge increased in the retention questionnaire, whereas non-peer-educators' knowledge decreased. Knowledge declined in the retention questionnaires for the other topics, although this was mostly not significant. Conclusions: This study indicates that peer education is an effective way to educate young people on important topics around health and hygiene, and to concurrently improve communication skills. Its use should be encouraged across schools to help in the implementation of the National Institute for Health and Care Excellence (NICE) guidance that recommends children are taught in an age-appropriate manner about hygiene and antibiotics.

Structure of the Branched-chain Amino Acid and GTP-sensing Global Regulator, CodY, from Bacillus subtilis.

CodY is a branched-chain amino acid (BCAA) and GTP sensor and a global regulator of transcription in low G + C Gram-positive bacteria. It controls the expression of over 100 genes and operons, principally by repressing during growth genes whose products are required for adaptations to nutrient limitation. However, the mechanism by which BCAA binding regulates transcriptional changes is not clear. It is known that CodY consists of a GAF (cGMP-stimulated phosphodiesterases, adenylate cyclases, FhlA) domain that binds BCAAs and a winged helix-turn-helix (wHTH) domain that binds to DNA, but the way in which these domains interact and the structural basis of the BCAA dependence of this interaction are unknown. To gain new insights, we determined the crystal structure of unliganded CodY from Bacillus subtilis revealing a 10-turn α-helix linking otherwise discrete GAF and wHTH domains. The structure of CodY in complex with isoleucine revealed a reorganized GAF domain. In both complexes CodY was tetrameric. Size exclusion chromatography with multiangle laser light scattering (SEC-MALLS) experiments showed that CodY is a dimer at concentrations found in bacterial cells. Comparison of structures of dimers of unliganded CodY and CodY-Ile derived from the tetramers showed a splaying of the wHTH domains when Ile was bound; splaying is likely to account for the increased affinity of Ile-bound CodY for DNA. Electrophoretic mobility shift and SEC-MALLS analyses of CodY binding to 19-36-bp operator fragments are consistent with isoleucine-dependent binding of two CodY dimers per duplex. The implications of these observations for effector control of CodY activity are discussed.

School Nurses' perspectives on the role of the school nurse in health education and health promotion in England: a qualitative study.

BACKGROUND: The role of the school nurse is complex with many possible elements identified by previous research. The aim of this study is to understand perceptions of the role of the school nurse in order to support school nurses in the delivery of health education. METHODS: The study used an inductive, qualitative research design involving semi-structured interviews and focus groups. Participants were recruited from four NHS trusts across England and final sample size was thirty one school nurses. Three focus groups and two interviews took place in person, and three interviews were over the phone. Data was thematically analysed. RESULTS: School nurses described six main themes. Four themes directly related to the school nurse role: the main roles of a school nurse, school nurses' role in health education, prioritisation of workload and activities, and community work. A further two other themes related to the delivery of health education: the school nursing system and educational resources. CONCLUSIONS: The role of the school nurse in England is very diverse and the school nurse role in health education is primarily to advise and support schools, rather than to directly deliver education. The study identified that tailored public health educational resources are needed to support school nurses.

Monitoring Web Site Usage of e-Bug: A Hygiene and Antibiotic Awareness Resource for Children.

BACKGROUND: e-Bug is an educational resource which teaches children and young people about microbes, hygiene, infection, and prudent antibiotic use. The e-Bug resources are available in over 22 different languages and they are used widely across the globe. The resources can be accessed from the e-Bug website. OBJECTIVE: The objective of this study was to analyze the usage of the e-Bug website in order to understand how users access the website, where and when they access the site, and to review variation in use across the different areas of the site. METHODS: The usage statistics for the e-Bug website were monitored by Google Analytics between September 2010 and August 2013. RESULTS: The statistics show the website had over 324,000 visits during the three years, from just under 250,000 visitors, with the number of visitors increasing year after year. Visitors accessed the website from 211 different countries, with more than 267,000 documents downloaded. The majority of visitors were from the United Kingdom and visited the English website, although countries such as France and Portugal were also frequent visitors. CONCLUSIONS: These website statistics confirm that e-Bug is frequently used across Europe and highlight that e-Bug use has expanded across the world. The findings from this report will be used to inform future modifications or updates to the materials, as well as the development of new educational resources.

Federally Qualified Health Centers' Capacity and Readiness for Research Collaborations: Implications for Clinical-Academic-Community Partnerships.

BACKGROUND: Federally qualified health centers (FQHCs) provide a health care safety net for underserved populations and contribute unique expertise to research that could further enhance quality of patient care. The purpose of this research was to assess interest in, readiness to, and capacity for conducting research in FQHCs in South Carolina (SC). METHODS: A Web-based survey was administered to 20 FQHCs across SC. Fourteen representatives of FQHCs completed the 39-item survey that assessed research experience and interest, partnerships and funding, barriers and benefits to research participation, training and technical assistance needs, and research capacity. RESULTS: FQHCs are interested in conducting research. FQHCs reported that health center leadership, organizational benefit, active engagement of staff, and clear roles for partners were important factors for successful partnerships. Inequity of budget and resources were the greatest challenges encountered. Improved patient outcomes, additional resources for the center, reduction in disparities, and academic partnerships were considered benefits for participation. FQHCs were interested in training and technical assistance opportunities for research funding and best practices for the use of research to inform programs and services. CONCLUSIONS: FQHCs are willing to collaborate on research. For successful research partnerships, collaborators should understand FQHCs' challenges and barriers to participation.

Decreased Cancer Mortality-to-Incidence Ratios with Increased Accessibility of Federally Qualified Health Centers.

Federally qualified health centers (FQHCs) offer primary and preventive healthcare, including cancer screening, for the nation's most vulnerable population. The purpose of this study was to explore the relationship between access to FQHCs and cancer mortality-to-incidence ratios (MIRs). One-way analysis of variance was conducted to compare the mean MIRs for breast, cervical, prostate, and colorectal cancers for each U.S. county for 2006-2010 by access to FQHCs (direct access, in-county FQHC; indirect access, adjacent-county FQHC; no access, no FQHC either in the county or in adjacent counties). ArcMap 10.1 software was used to map cancer MIRs and FQHC access levels. The mean MIRs for breast, cervical, and prostate cancer differed significantly across FQHC access levels (p < 0.05). In urban and healthcare professional shortage areas, mean MIRs decreased as FQHC access increased. A trend of lower breast and prostate cancer MIRs in direct access to FQHCs was found for all racial groups, but this trend was significant for whites only. States with a large proportion of rural and medically underserved areas had high mean MIRs, with correspondingly more direct FQHC access. Expanding FQHCs to more underserved areas and concentrations of disparity populations may have an important role in reducing cancer morbidity and mortality, as well as racial-ethnic disparities, in the United States.

A Prospective Multi-Center Audit of Nutrition Support Parameters Following Burn Injury.

The importance of nutrition support delivery to the severe burn-injured patient is well recognized, however, nutrition provision to the patient may be sub optimal in practice. The aim of this study was to conduct a prospective multi-center audit across Australia and New Zealand using the Joanna Briggs Institute Burns Node Nutrition audit criteria. Thirty-four patients with severe burn injury (≥20% TBSA in adults and ≥10% TBSA in children) were identified on admission or on referral to the Dietitian at the eight participating Burn Units between February 1, 2012 and April 30, 2012 for inclusion in the study. De-identified patient data was analyzed using the Joanna Briggs Institute, Practical Application of Clinical Evidence System. Compliance with individual audit criterion ranged from 33 to 100%. Provision of prescribed enteral feed volumes and weekly weighing of patients were highlighted as key areas for clinical improvement. Clinical audit is a valuable tool for evaluating current practice against best evidence to ensure that quality patient care is delivered. The use of the Joanna Briggs Institute Burns Node audit criteria has allowed for a standardized multi-center audit to be conducted. Improving nutrition support delivery in burn patients was identified as a key area requiring ongoing clinical improvement across Australia and New Zealand. Clinician feedback on use of the audit criteria will allow for future refinement of individual criterion, and presentation of results of this audit has resulted in a review of the Bi-National Burns Registry nutrition quality indicators.

Practice adaptive reserve and colorectal cancer screening best practices at community health center clinics in 7 states.

BACKGROUND: Enhancing the capability of community health centers to implement best practices (BPs) may mitigate health disparities. This study investigated the association of practice adaptive reserve (PAR) with the implementation of patient-centered medical home (PCMH) colorectal cancer (CRC) screening BPs at community health center clinics in 7 states. METHODS: A convenience sample of clinic staff participated in a self-administered, online survey. Eight PCMH CRC screening BPs were scored as a composite ranging from 0 to 32. The PAR composite score was scaled from 0 to 1 and then categorized into 3 levels. Multilevel analyses examined the relation between PAR and self-reported implementation of PCMH BPs. RESULTS: There were 296 respondents, and 59% reported 6 or more PCMH BPs at their clinics. The mean PAR score was 0.66 (standard deviation, 0.18), and the PCMH BP mean scores were significantly higher for respondents who reported higher clinic PAR categories. In comparison with the lowest PAR level, adjusted PCMH BP means were 25.0% higher at the middle PAR level (difference, 3.2; standard error, 1.3; t = 2.44; P = .015) and 63.2% higher at the highest PAR level (difference, 8.0; standard error, 1.9; t = 4.86; P < .0001). CONCLUSIONS: A higher adaptive reserve, as measured by the PAR score, was positively associated with self-reported implementation of PCMH CRC screening BPs by clinic staff. Future research is needed to determine the PAR levels most conducive to implementing CRC screening and to develop interventions that enhance PAR in primary care settings.