Mapping educational opportunities for healthcare workers on antimicrobial resistance and stewardship around the world

In total, we identified 94 educational initiatives related to AMR/AMS. The 94 initiatives represent a diverse array of programs including formal courses, workshops, conferences, guidelines, public outreach materials, and online-resource websites. The complete list of initiatives is presented in Table 1.

We identified 24 multi-component umbrella programs, which typically included web-based resources, videos, references to guidelines, and promotional materials, such as posters, pamphlets, or infographics. Programs that incorporated four or more program types were defined as umbrella programs. Umbrella programs tended to have broader target audiences and wider scopes; in many cases, their awareness campaign materials were targeted towards a general audience, while online reading and guidelines were more often aimed at HCWs. Many umbrella programs targeted their messaging at HCWs—including physicians, pharmacists, and sometimes nurses—as a group, rather than targeting professions or specialties individually.

Of the programs identified (see Fig. 1), the most common program type was websites; typically, however, online resources were only part of a larger program. This is unsurprising as online resources are effective platforms for sharing other program types, including videos, guidelines, pamphlets, and workbooks. Guidelines and handbooks were also a common resource, often shared online in government and hospital education initiatives; these described information about key patient populations and prescribing guidelines and were intended as reference resources. By contrast, we also identified a small number of workbooks and question sets intended as a teaching resource.

Other teaching resources available online included videos, webinars, and lecture slides. Online courses, including massive open online courses (MOOCs), are becoming common and often incorporate online videos and discussion boards to engage participants. In Fall 2016, there were two MOOCs on the FutureLearn platform (see Initiatives #44 and #90). The MOOC run by the University of Dundee and British Society for Antimicrobial Chemotherapy (Initiative #90) has gained global popularity. Several experts referenced this course as a resource used in their country; the course has been offered three times to date and participants have come from more than 41 countries.

Figure 2 shows participating organizations grouped by type. Overall, the most commonly identified organizations were governmental bodies, often the national/provincial/state-level body responsible for health and/or education. We also found that health insurance companies often partnered with other organizations in the USA to support AMR education campaigns. Collaborations with industry came almost entirely from North America. Outside of the USA, the only other campaigns that partnered with a health insurance provider were in France. The European Centre for Disease Control contributed to the bulk of projects which we tagged as intergovernmental organizations.

Professional societies, particularly those with a strong tie to AMR, were heavily involved in the creation and provision of resources for HCWs. Three examples are the British Society for Antimicrobial Chemotherapy, which has been involved in the creation of resource websites (Initiative #48), coordination of a MOOC (Initiative #90), and provision of funding for AMR education; the European Society of Clinical Microbiology and Infectious Diseases, which runs a study group on antimicrobial resistance, develops and coordinates courses, and carries out collaborative academic research; and the Infection Control Africa Network which organized a free distance learning course for HCWs in Africa in 2014. Many professional bodies with broader mandates, for example, medical associations and pediatric societies, have partnered with others to support larger projects, but were rarely the lead organization in the projects that we identified. For example, the NPSMedicineWise project (Initiative #82) in Australia engaged the Australian College of Nursing, Australian Association of Consultant Pharmacy, the Australian College of Rural & Remote Medicine, and the Australian Nursing and Midwifery Federation and many others alongside government bodies to produce resources and course content for the website.

University-led projects were typically related to online or in-person courses or to resource websites. Many of these sites provide lecture slides, or recorded video lectures (e.g. Initiative #16), as well as information on guidelines and policies (e.g. Initiative #35). Other types of organization were engaged in a wide variety of projects. Hospitals and healthcare centers, for example, engaged with umbrella programs, courses and workshops, intervention studies, and resource guides.

Most programs targeted HCWs as a broadly defined group. Figure 3 shows the target audiences for the 94 programs identified. Several programs also included components aimed at patients and the public. We found 33 programs aimed at physicians, including a small number that targeted specialists such as infectious disease physicians and pediatricians. Fewer programs specifically targeted nurses, pharmacists, and midwives, though these groups were targeted in the more general HCW programs. A small number of predominantly university-based programs targeted medical or pharmacy students. Four programs, mostly courses and workshops, targeted clinical microbiologists alongside other HCWs.

We identified programs from around the world, though, as expected, the programs were unequally distributed between countries and regions, with a larger share of the programs from North America and Europe. Figure 4 shows a map of the number of programs identified from each region. Many of the large-scale AMR/AMS educational campaigns took place in wealthy American and European countries (e.g. Initiatives #15 and #59), whereas many of the programs in Africa and Asia were workshop or course based (e.g. Initiatives #1, #78, #83). The interconnected nature of some programs made them more easily producible on the part of the organizations and more easily identifiable on our part as researchers. This strategy facilitated the growth of programming in specific regions, and has made online information about AMR/AMS widely available to HCWs and the public. For instance, state-specific AMR educational initiatives, such as “Get Smart Colorado: Use Antibiotics Wisely” (Initiative #17), appeared to tailor resources or share/endorse existing resources from the comprehensive national “Get Smart” program (Initiative #15) produced by the CDC in the USA.

We identified a small number resources for students in healthcare disciplines, though research suggests that medical students in Europe and the USA have a desire for increasing training on AMR [11, 12]. Researchers from the ESCMID Study Group for Antibiotic Policies have suggested that undergraduate training should be focused on principles of AMS and building good prescribing habits [12]. Resources on these topics are available, as the MOOCs we identified often included lectures, videos, and case studies on these themes. Students, however, are unlikely to have the time to pursue these courses outside their educational program. Educational research also suggests that training at the undergraduate level should ideally be delivered through active learning sessions which allow students to integrate knowledge with practice [12, 13]. We note that the small number of programs specifically targeting students have embraced opportunities for active student participation and interaction. To support their curriculum for medical students (Initiative #16), Wake Forest University designed series of small-group case studies with facilitator guides to allow group discussions of AMR issues. In Canada, the Do Bugs Need Drugs? Program (Initiative #14) has engaged students from medicine, pharmacy, nursing, and dentistry in delivering educational messages on AMR to students in elementary school. Canadian medical students have also been active in developing their own opportunities for AMR/AMS learning. In 2014, students at the University of Toronto created the Students for Antimicrobial Stewardship Society, which has now expanded to include students in dentistry and pharmacy and at other medical schools. The students have launched an annual awareness campaign on AMR, and organized educational lectures and interprofessional panels on stewardship to provide students with opportunities to ask questions (Initiative #37). Given the small number of programs that engage with students, there are undoubtedly more opportunities to develop resources for students. These might include the creation of educational curricula and support resources including videos and case studies, or engagement of students and student societies in broader educational programs.

We found that many excellent courses already exist, and several are available online at low or no cost. As content is already available, improving roll-out is a matter of ensuring that these courses can run repeatedly; preparing a course for a single session is likely a waste of resources. Another way to improve roll-out is to facilitate translation of course materials to other languages. Consulted experts noted that translating available content, such as a MOOC, from English into other languages is a slow and difficult process. Beyond the translation of lecture slides, there is a need to obtain other resources, such as academic articles and video content, in the foreign language. Creation of a database that brings together resources on AMR/AMS in other languages would facilitate the adaptation of courses between languages.

Improving uptake of existing educational opportunities is also key. We note that among the resources identified, very few are accredited as continuing professional education. This is probably a major oversight—and opportunity—as evidence suggests that HCWs are not receiving enough training on AMR/AMS [14]. HCWs would likely be incentivized to participate if the courses were accredited as CME, as HCWs in many countries must undertake several hours of CME per year. Experts that we consulted expressed a desire for courses qualifying as CME, but found the accreditation process challenging and slow. To date, most courses have been developed by academic societies and there is an opportunity here for greater collaboration between academic societies and professional societies. Academic societies have knowledge and resources at their disposal and, by partnering with professional societies such as pediatric societies or nurses associations, could adapt their existing programs to meet the specific training needs of these healthcare specializations and provide training to a larger number of HCWs. Regulators and professional councils should be engaged in devising strategies to facilitate the uptake and scale-up of AMR-related pre-service education and in-service training initiatives.

Many of the programs that we identified made their content freely available online. In addition to courses, we found lecture slides, video lectures, case studies, facilitator guides, handbooks, posters, and other campaign materials online. The presence of these many high-quality resources online suggests that it is not necessary for new educational campaigns and courses to reinvent the wheel; a large amount of information is already available. However, much of this content is scattered across the web. It would be very useful to develop a resource site or database of good AMR content. Collecting this content would allow educators to build off of existing educational materials and focus their efforts on developing course content specific to the local context. The ReAct Toolbox (Initiative #94) is an excellent model, providing basic information on several aspects of AMR/AMS and links to other online resources that are relevant to both LMICs and high-income countries. The main limitation of the site, and many of the other educational resources that we have identified, is that many resources are only available in English.

This project is the first attempt that we know of to map educational resources for HCWs around the world. We contacted more than 50 experts and identified educational resources and projects in all WHO regions. By identifying and classifying programs, we can see the breadth of resources already available for training HCWs on AMR/AMS.

As we relied extensively on web searching in addition to expert advice, it is likely that we identified more of some types of resource than others. Therefore, the quantity of identified programs of this type should not be interpreted as proof that these resources are the most common program type. We paired our web searching with expert input to identify those other resources that are more difficult to identify online. We recognize that some web resources, such as guidelines, are more likely to endure on the internet than others, such as advertisements for courses and conferences. We included mobile apps specific to antibiotic resistance if they were identified by experts or identified in web searches. However, it was beyond the scope of the study to search within existing medical apps to locate AMR/AMS content; this has been done elsewhere by Goff et al. [15].

We conducted our web and academic searching in English and relied upon on expert contacts to provide information on educational programs in other languages. We identified and reviewed some educational programs where the detailed information online was in French, but did not translate articles from other languages, and therefore likely missed other educational resources posted online that are only available in other languages.

Finally, we note that longevity of resources on the internet is an issue. We found many broken links, where program information could no longer be obtained. We identified many courses through course advertisements posted to the web; however, the limitations of our search strategy make it likely that we mainly identified recent courses. Further, for most courses, we cannot comment as to whether the course content has been archived on the web. While much of the content from a larger course, such as a MOOC, is likely to remain on the web, it is unlikely that the course content of shorter, in-person courses will be retained in the same way. Resource sites must monitor content to ensure it remains up to date. To facilitate the sharing of resources between countries, it will also be important to find a mechanism such that content does not become inaccessible after removal from the website.