Context
Spoiler alert. There’s another pandemic on its way. It’s silent and quite deadly (BBC Ideas 2022; O’Neill 2016). Antimicrobial resistance (AMR), which occurs when bugs develop the ability to defeat the medicines (e.g., antibiotics) designed to kill them, poses a major threat to human health. Infection and protection control (IPC) training has a vital role to play in containing the rise of AMR, both by reducing infections and in the prescribing of antibiotics. The microbiological sciences and IPC regimes are vital for understanding the nature and behaviours of pathogens, their effects on us, and the best ways to mitigate their undesirable consequences. Conventional approaches to IPC training are very much predicated on content from these dominant epistemologies (e.g., NHS Education Scotland 2023).

Question
Given that each and all of us must play our part in reducing infections and antibiotic use, are these current approaches to IPC training - alone - the most effective way of engaging the wider lay public and non-specialist professionals, and influencing preventative behaviours?

Findings from prior studies
This paper reflects on the findings of two approaches, in linked but separate studies, to developing IPC training interventions for a range of healthcare professionals (HCP). Each involved an inter-disciplinary team, the co-development of content, novel visual methods to ‘make the invisible [pathogens and behaviours], visible’, and an interactive digital model of the environment in which infection scenarios were acted out on a tablet or mobile app. Involved in the co-design process within each study was a mixed team of research disciplines including co-design, software engineering, microbiology, IPC training, and nursing or veterinary practice, as well as non-team participants development workshops.

Study 1: hospital ward
Content was heavily influenced by microbiological sciences and proven efficacy of IPC regimes, naming common healthcare acquired infections (HAI) found in the hospital ward setting, their locations within environments or people, routes of transmission, persistence, and impact of IPC measures. The novelty was in portraying typical IPC scenarios in a visual and interactive manner within a digital model of the hospital ward (figure 1). Participant trainees reported improved awareness and understanding of the pathogens responsible for HAI, and the types of information relevant for different staff cohorts. The tool appeared to offer staff a new perspective on pathogens, being able to ‘see’ them contextualised in the virtual ward, making them seem “more real [about] what we know in theory” (Macdonald et al. 2017).

Figure 1: A screen from one of the interactive tablet-based training tool prototypes, developed during the hospital-based study, visually highlighting different pathogens, and the locations (reservoirs), survival and routes of transmission for each.

Study 2: veterinary practice
Set in a digital model of a veterinary practice (figures 2a,b,c), this departed from typical microbiological and IPC training content and approaches. Pathogens were not named but implicated in scenarios inviting trainees to identify primary and secondary sources of infection, behaviours (risky or precautionary) potentially spreading or containing infections and mitigating IPC measures. Driving the central narrative was the question: ‘What can be done to get [the dog] into theatre with as little contamination as possible’. This approach was found to change perception of risky behaviours in a sample population of veterinary practitioners; after experiencing training, 92% participants agreed to change their behaviour and stated an intention to implement an IPC behaviour that aligned with training objectives. Trainees also found that the 3D graphics enhanced the delivery of training content by making difficult and abstract contamination concepts easy to understand (Macdonald et al. 2020). A post study reflection on study 2 reappraised its approach as a form of ‘serious story’ (Macdonald et al. 2023) discussed with reference to the achievements in the field of serious health games (e.g., Wang at al. 2016; Maheu-Cadotte 2021a; Maheu-Cadotte et al. 2021b).

Figure 2: The AMRSim/VIPVis studies developed a three-layered interactive training tool to: a) prompt identification of potential infection risks in the monochrome layer animated sequences (upper); b) reveal potential direct/indirect contamination sources through the ‘red’ layer (middle); and c) show the mitigating effects of infection prevention and control measures through the green layer (lower).

Discussion
There is little robust evaluation of the effectiveness of current IPC training. This paper develops the discussions in prior publications of these two studies to explore, in greater depth, the potential opportunities afforded by questioning the epistemological conventions of IPC training as the sole approach to be considered when engaging the wider, non-IPC specialist audience. It also questions the necessity of extended training programmes for busy, time-pressed non-IPC professionals and the wider public and asks what might be achieved through short, generic and engaging IPC training packages that might quickly change perception of infection risk sufficiently to change behaviour.

Conclusions
It is clear that a prospective AMR pandemic poses a significant threat and will require all to engage with the challenge. The author posits that creative approaches to IPC training, derived from the arts and humanities, may offer accessible, effective techniques for training and awareness-raising, helping to achieve desired shifts in perception and behaviour, and providing a useful complementary role, alongside more conventional approaches, in helping to containing AMR.

Acknowledgements
Although the opinions expressed here are purely those of the author, he is deeply indebted to those colleagues and participants involved in the studies above. The author also acknowledges funding from the AHRC for these studies: AHRC Follow-on Fund Ref: AH/M00628X/1; AHRC AMR Theme 3b Grant Ref: AH/R002088/1; AHRC Follow-on Grant Ref: AH/V001795/1.

Selected References

BBC Ideas. 2022. “What Would a World Without Antibiotics Be Like?” https://www.trin.cam.ac.uk/news/dame-sally-davies-features-in-new-film-about-the-silent-pandemic/

Macdonald, A.S., C. Macduff, D. Loudon, and S. Wan. 2017. “Evaluation of a Visual Tool Co-developed for Training Hospital Staff on the Prevention and Control of the Spread of Healthcare Associated Infections.“ Infection, Disease & Health 22 (3): 105-116. https://www.idhjournal.com.au/article/S2468-0451(17)30020-2/abstract

Macdonald, A., M. Chambers, R. La Ragione, K. Wyles, M. Poyade, A Wales, N. Klepacz, T. Kupfer, F. Watson, and S. Noble. 2020. “Addressing Infection Risk in Veterinary Practice through the Innovative Application of Interactive 3D Animation Methods.” The Design Journal 24 (1): 51-72. https://doi.org/10.1080/14606925.2020.1850225

Macdonald. A.S., O. McCorry, M. Poyade, C. Trace, and M. Chambers. 2023. “The Art of Serious Storytelling: Using Novel Visual Methods to Engage Veterinary Practitioners in Reducing Infection Risk During Preparation for Surgery.” In Teaching, Research, Innovation and Public Engagement: New Paradigms in Healthcare, edited by Ourania Varsou, 91-107. Cham: Springer. https://link.springer.com/chapter/10.1007/978-3-031-22452-2_8

NHS Education Scotland (NES). 2023. “Antimicrobial Resistance and Healthcare Associated Infections (ARHAI)”.
https://www.nes.scot.nhs.uk/media/rm1iwv45/arhai-leaflet-spring-2023.pdf

Maheu-Cadotte M-A, S. Cossette, V. Dubé, G. Fontaine, A. Lavallée, P. Lavoie, T. Mailhot, and M-F. Deschênes. 2021a. “Efficacy of Serious Games in Healthcare Professions Education: A Systematic Review and Meta-analysis.” Simulation in Healthcare 16 (3): 199–212. https://doi.org/10.1097/SIH.0000000000000512

Maheu-Cadotte M-A, V. Dubé, S. Cossette, A. Lapierre, G. Fontaine, M-F. Deschênes, and Lavoie P. 2021b. “Involvement of End Users in the Development of Serious Games for Health Care Professions Education: Systematic Descriptive Review.” JMIR Serious Games 9 (3):e28650. https://doi.org/10.2196/28650

O’Neill, J. 2016. “Tackling Drug-Resistant Infections Globally: Final Report and Recommendations. The Review on Antimicrobial Resistance.” Wellcome Trust/HM Government. https://iiif.wellcomecollection.org/file/b28644797_160525_Final%20paper_with%20cover.pdf

Wang R, S. DeMaria Jr, A. Goldberg, and D. Katz. 2016. “A Systematic Review of Serious Games in Training Health Care Professionals.” Simulation in Healthcare 11 (1): 41–51. https://doi.org/10.1097/SIH.0000000000000118