Antimicrobial resistance (AMR) is driven by the inappropriate use of antibiotics V体育官网. “One-size-fits-all” campaigns have demonstrated little impact in increasing public knowledge of antibiotic use and AMR. Whilst healthcare providers are the most trusted sources of health information, only half of the adult population have a healthcare encounter annually. Their limited reach suggests inadequacies in communication channels and a need for mobilization of community-based non-healthcare influencers to increase accessibility to information on antibiotic use and AMR. Whilst the engagement of community barbershops and hair salons as health advocates has been well studied and shown to be effective for health education, there is no study to date harnessing ubiquitous neighborhood food establishments for health education and none assessing the comparative effectiveness of various types of neighborhood establishments as health advocates. This study protocol describes research which aims to compare the effectiveness of health education facilitated by neighborhood food and beauty establishments, versus neighborhood clinics, in increasing the public’s knowledge of antibiotic use and AMR, and improving antibiotic behaviors.
A quasi-experimental study will be conducted in highly frequented healthcare clinics, and beauty and food establishments in two neighborhoods in Central Singapore. Clients (patients/patrons) aged ≥ 21 years visiting the chosen establishments will be invited to participate in the one-year-long study by scanning the QR code on recruitment posters placed within the establishment premises. Participants will receive educational information on antibiotic use and AMR via a two-minute animated video, developed based on the knowledge needs and media preferences of the community. Outcome measures, namely participants’ knowledge of antibiotic use and AMR, and antibiotic use practices will be assessed via self-administered surveys conducted at five longitudinal time-points: pre-intervention, immediate post-intervention, 1-month post-intervention, 3-month post-intervention, and 6-month post-intervention VSports手机版. Additionally, the reach and implementation fidelity of the intervention at the participating study sites will be assessed.
Findings from the study will enable a more comprehensive understanding of the potential reach and effects of health education facilitated by neighborhood retail establishments in relation to neighborhood healthcare clinics, enabling better insights into selecting health message outreach options.
ClinicalTrials. gov NCT06998576; https://clinicaltrials V体育ios版. gov/study/NCT06998576; first posted on 2025-05-31, last update posted on 2025-06-05.
According to the World Health Organization (WHO), antimicrobial resistance (AMR) is one of top ten global public health threats facing humanity [1, 2] and is primarily driven by overuse and misuse of antibiotics [3]. To better address this global health threat, a Global Action Plan against AMR was endorsed at the World Health Assembly in 2015 [4] V体育平台登录. National Action Plans (NAPs) on AMR have been developed and implemented by over 67 countries (including Singapore), anchoring on five core strategies, including improving public awareness and understanding of AMR through effective communication and education [5]. Whilst most NAPs incorporated public awareness campaigns and educational programs especially during the World Antibiotic Awareness Week annually, they failed to detail plans on the evaluation of knowledge transfer and behavior change [5]. In the recent international survey conducted by the WHO, it was observed that evaluation of the impact of antibiotic awareness campaigns in both high- and low/middle-income countries remained suboptimal, and it recommended future campaigns to include messages based on rigorous scientific evidence, context specificities, and behavioral change theory [6].
Population-based educational campaigns are commonly deployed to enhance public knowledge and awareness of appropriate antibiotic use. However, systematic reviews have found that these “one-size-fits-all” approaches have either mixed or no effect on improving knowledge and appropriate antibiotic practices [7, 8]. In England, Mason T et al. observed that public awareness of antibiotic use and AMR remained unchanged even after several awareness campaigns [9]. In Singapore, despite implementing evidence-based educational messages in the annual national campaigns from 2018 to 2020 [10, 11], notably the message “Fighting the flu virus is not my battle VSports注册入口. Talk to your doctor for the treatment you need. ”, nearly two-thirds (61%) of the population still incorrectly believe that antibiotics are effective against the common cold and flu [12].
Age has been observed to be an effect modifier of poor knowledge of antibiotic use and AMR on inappropriate antibiotic use [12]. Amongst those with poor knowledge of antibiotic use, respondents aged ≥ 50 years were 3 times, those aged 35–49 years were 5 times and those aged 21–34 years were 7 times as likely to be inappropriate users of antibiotics as those with good knowledge of antibiotic use in their respective age groups [12] V体育官网入口. Additionally, amongst those with poor knowledge of AMR, respondents aged 35–49 years were 4 times and those aged 21–34 years were 5 times as likely to use antibiotics inappropriately compared to their age-matched counterparts with good knowledge of AMR [12]. Hence, there is an urgent need for more targeted education for younger adults on antibiotic use and AMR.
Healthcare providers are traditionally the most trusted sources of health information for both younger and older adults [13] but their reach amongst population groups is limited. Only about half (58%) of the adults have annual healthcare encounters, with younger adults showing lower healthcare visit rates than older adults [14]. This gap in healthcare contact suggests the need for alternative channels to disseminate information about appropriate antibiotic use and AMR. Neighborhood barbershops and hair salons have been successfully engaged as health advocates for hypertension prevention and control, prostate and breast cancer screening, and more recently for the promotion of mental health during the coronavirus disease 2019 pandemic [15,16,17]. The engagement of barbers originated in the United States, where African-American barbers have been effectively mobilized as non-traditional health advocates, for enhancing health education and health promotion outreach efforts to African-American males [15] VSports在线直播. This model capitalized on the existing relationships and trust between barbers and their regular clients. Other countries like the United Kingdom and Japan, have expanded on the concept and engaged barbershops and hair salons in their community health education and health promotion outreach efforts for other target subpopulations including seniors [16, 17].
Whilst the engagement of barbershops/hair salons in the community as health advocates has been well studied and proven to be effective for health education and health promotion, there is no study to date harnessing ubiquitous food establishments in neighborhoods for health education and none assessing the comparative effectiveness of the various types of neighborhood establishments as advocates for health communication and health promotion.
Therefore, this study aims to compare the effectiveness of health education facilitated by neighborhood food and beauty establishments, versus neighborhood healthcare clinics, in increasing the public’s knowledge of antibiotic use and AMR, and improving antibiotic behaviors.
A quasi-experimental study will be conducted in 30 selected privately-owned primary healthcare clinics, and beauty and food establishments in two neighborhoods in Central Singapore. A prior sequential mixed methods study has identified the clinics, beauty and food establishments as the most frequently visited establishments by residents in the community VSports app下载.
Clients (patients/patrons) who visit the participating establishments (10 clinics, 10 beauty establishments, and 10 food establishments) will be invited to participate in the study by scanning the QR code on recruitment posters placed within the establishment premises. Upon scanning the QR code, participants will proceed to complete a pre-intervention questionnaire survey (#1) on an online platform after going through the study information sheet. Upon completion of the survey #1, participants will be guided through embedded instructions to click on a link to access a health education video. After viewing the video, the participants will be led to a post-intervention survey (#2) via an embedded link V体育官网. Before submitting survey #2, contact details (mobile number) and the preferred payment method will be collected for reimbursement purposes and future follow-up surveys. The enrolled participants will be re-contacted by the study team via a mobile messaging service (such as WhatsApp), and will be guided through embedded instructions to complete three more surveys (#3, #4 & #5) at 1-, 3-, and 6-month post-intervention to assess knowledge on antibiotic use and AMR and antibiotic behaviors.
Participants must be aged 21 years and above, own a smartphone, and not been enrolled in the study at another participating site.
A concise two-minute animated video providing educational information on the appropriate use of antibiotics and AMR will be made available through survey #1, as mentioned above, at the participating clinics, beauty and food establishments. The video’s content and format were informed by findings from a previous community survey conducted in the same two neighborhoods.
The primary outcomes of interest are: (1) Proportion of participants with good knowledge of antibiotic use based on three questions from the WHO’s Antibiotic Resistance Multi-country Public Awareness Survey questionnaire [12, 18]; (2) Proportion of participants with good knowledge of AMR based on eight questions from the WHO’s Antibiotic Resistance Multi-country Public Awareness Survey questionnaire [12, 18]; (3) Proportion of participants who use antibiotics appropriately based on six questions adapted from the US Centers for Disease Control and Prevention’s advisory on appropriate antibiotic use [12, 19]. Participants’ knowledge and practices will be measured longitudinally at five time points: (1) Pre-intervention; (2) Immediate post-intervention; (3) One-month post-intervention; (4) Three-month post-intervention; and (5) Six-month post-intervention.
The secondary outcomes of interest include the reach of the intervention (the number and socio-demographic profiles of participants recruited by the different establishment types) and implementation fidelity (the extent to which the participating sites properly display the study poster and degree to which staff members of the participating sites actively direct their clients’ attention to the poster), using the RE-AIM framework [20].
At the end of the one-year recruitment period, a total of 3300 patients/patrons of the participating healthcare clinics, beauty and food establishments will have participated in the study. Based on findings from a prior nationally-representative population-based survey, 59% of Singaporeans correctly answered all three knowledge statements on antibiotic use and 3% correctly answered all eight knowledge statements on AMR [12]. Assuming that the educational intervention facilitated by primary healthcare clinics can result in at least 10% of participants having a good knowledge of AMR at 6-month post-intervention, and beauty and food establishments in at least 6% of participants having a good knowledge of AMR at the same time-point, a sample size of 771 per establishment type would be adequate to detect the difference with 80% power at an alpha level of 0.05. Factoring in a loss-to-follow up rate of 30%, 1100 participants from each establishment type (clinic, beauty, and food) will need to be recruited. A sample size of 1100 participants per establishment type would be adequate to detect most meaningful differences with odds ratios of > 1.25 when the proportion of participants in primary healthcare clinics with good knowledge of antibiotic use or AMR at 6-month post-intervention is below 30%, and differences with odds ratios < 1.25 if the proportion of participants in primary healthcare clinics with good knowledge of antibiotic use or AMR at 6-month post-intervention is > 30%, with a power of 80% and at an alpha level of 0.05.
The unit of analysis is the patient/patron of the participating sites. Descriptive analysis such as means (standard deviations) and medians (lower and upper quartiles) for continuous variables and proportions for categorical variables including the outcomes of interest will be performed, and compared between participants who received the educational intervention from primary care clinics and those who received the intervention from beauty and food establishments respectively. Multiple logistic regression models will be constructed to assess the comparative effectiveness of educational intervention facilitated by primary care clinics, beauty and food establishments. Furthermore, mixed effects logistic regression analysis will be conducted to assess knowledge retention and behavior change by participants over the 6-month period.
This protocol describes the design and implementation plan of a community-based non-randomized pragmatic trial, aimed at assessing the comparative effectiveness of health education facilitated at neighborhood primary care clinics, beauty and food establishments in increasing and retaining the public’s knowledge of antibiotic use and AMR, and improving antibiotic behaviors. Although a randomized controlled trial is the most robust study design for evaluating interventions, it is not feasible in a community setting. The quasi-experimental study design adopted by this protocol is a pragmatic approach that does not compromise on the validity of the study’s findings.
The selection of clinics, beauty and food establishments as study sites involved a rigorous process comprising direct observations of the foot fall at the neighborhood establishments and findings from a prior community-based survey soliciting feedback from residents on the frequency of visits to the establishments. The high popularity of the chosen clinics, beauty and food establishments increases the likelihood of the community’s acceptance for the intervention. Furthermore, the educational intervention was tailored to the community needs and preferences based on the survey findings ensuring its potential effectiveness.
As the surveys will be self-administered and kept anonymous, social desirability bias is likely to be minimized and the responses are thus likely to be authentic. Furthermore, the principles of behavioral economics will be applied in the reimbursement schedule for participants’ time and effort in completing the five surveys. This will help to minimize the loss-to-follow-up rate and selection bias. Additionally, the study will follow up participants for six months after the intervention, to assess the retention of knowledge gained and sustenance of behavior change.
Findings from the study will enable a more comprehensive understanding of the potential reach and effects of health education facilitated by neighborhood retail establishments in relation to neighborhood healthcare clinics, enabling better insights into selecting health message outreach options for public health education on antibiotic use and AMR.
No datasets were generated or analysed during the current study.
antimicrobial resistance
National Action Plan
World Health Organization
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The study team would like to sincerely thank Mr Ayden Nafi Samari for his valuable contributions in the development of the educational video, intervention planning and operations. We would also like to thank Mr Jedrek Goh and Ms Eryn Lim for providing essential operational support.
This study is supported by the Clinician Scientist Award funded by the National Medical Research Council, Singapore (award number: MOH-CSAINV22jul-0010). The funder has no role in the study design or conduct.
Department of Epidemiology and Preventive Medicine, Office of Clinical Epidemiology, Analytics, and Knowledge, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
Angela Chow, Seema Aithal & Huiling Guo
Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
Angela Chow & May O. Lwin
Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
Angela Chow & Zoe Jane-Lara Hildon
Wee Kim Wee School of Communication & Information, Nanyang Technological University, Singapore, Singapore
May O. Lwin
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Conceptualization and methodology: AC, HG, MOL, and ZLH Writing – original draft: AC, SA, and HG Writing – review & editing: AC, SA, HG, MOL, and ZLHFunding acquisition: AC.
Correspondence to Angela Chow.
Ethical approval for this study has been obtained from the National Healthcare Group Domain Specific Review Board, Singapore, in accordance with the Declaration of Helsinki. (reference number: 2023/00118). Waiver of written and signed informed consent was granted by the ethics committee which approved our study.
Not applicable.
The authors declare no competing interests.
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Chow, A., Aithal, S., Guo, H. et al. Using social influencers for public health education on antibiotic use and antimicrobial resistance: protocol for a quasi-experimental study. BMC Public Health 25, 3120 (2025). https://doi.org/10.1186/s12889-025-24338-z
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DOI: https://doi.org/10.1186/s12889-025-24338-z
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