In the absence of a paid public service announcement campaign, the Oregon AWARE coalition has generated media coverage through a number of creative strategies, including a staged media event, press releases, and release of expert editorial opinion pieces to newspapers. We have augmented this effort by placing informational articles in newsletters generated by health plans, parent-teacher organizations, childcare provider groups and school nurses, and by launching a consumer-friendly Web site. These educational efforts encourage consumers to develop realistic expectations about receipt and use of antibiotics before unpleasant symptoms prompt them to seek medical attention.

Posters and brochures in clinic waiting rooms reinforce realistic expectations and encourage patients to ask for the most appropriate symptomatic treatments rather than to simply request antibiotics. A variety of staff, as well as the clinician, may present these materials.

Because antibiotic prescribing rates are particularly high for children aged 0-6 years (McCraig, Besser & Hughes, 2002), Oregon AWARE is now making a special effort to reach the parents of young children with information about appropriate use. Partnerships have been established with childcare provider groups and early childhood education programs. Future educational interventions will aim to reduce the incidence of upper respiratory infections and promote parent and staff awareness of the observation option for otitis media (AAFP/AAO-HNS/AAP, 2004). New child care provider training curricula will emphasize the importance of following standard disinfection procedures and reinforce recommendations regarding frequent, thorough hand washing among children and child care staff.

Oregon AWARE also provides direct continuing education for clinicians. The Oregon AWARE medical director and infectious disease consultants have given regular presentations at statewide and local conferences. This group collaborated to produce a self-study, continuing medical education booklet, entitled Judicious Use of Antibiotics: A Guide for Oregon Clinicians. The monograph is approved for one hour of continuing education credit for physicians, physician assistants and nurses. It provides a local perspective on the issue of antibiotic resistance, as well as the pharmacokinetic and pharmacodynamic principles that guide rational use of antibiotics. It also outlines consensus-derived treatment guidelines for pediatric and adult cough illness, sinusitis, pharyngitis, and pediatric otitis media. Oregon AWARE mailed the monograph to 6,500 primary care clinicians in 2003.

Evaluation of Combined Program Impact
Because behavior change is a long-term phenomenon, it will take several years to evaluate the results of this integrated public/patient/clinician education effort. Our evaluation utilizes multiple components to assess antibiotic use and patient/clinician attitudes about antibiotics from several perspectives. First, the resident curriculum project uses chart abstract data to determine prescribing rates for five common upper respiratory infections before and after implementation of the curriculum. Using Oregon Medicaid claims data, the AWARE program determined crude baseline antibiotic prescribing rates for sinusitis, acute bronchitis, pharyngitis, acute otitis media, and upper respiratory infection (common cold) in 2000. Based on these rates, we are targeting a 40% reduction in prescribing rates, and are abstracting data from charts of patients seen with these diagnoses in the respiratory season (November – March) of the years preceding and following curriculum implementation.