key: cord-0314710-4vwvnths
authors: Tyrrell, Jonathan M.; Conlon, Christie S.; Aboklaish, Ali F.; Hatch, Sarah; Smith, Carl; Mathias, Jordan; Thomson, Kathryn; Eberl, Matthias
title: ‘Superbugs: A Pop-up Science Shop’: Increasing public awareness and knowledge of antimicrobial resistance by taking science to the city
date: 2021-06-17
journal: bioRxiv
DOI: 10.1101/2021.06.16.443502
sha: b8f7692709b3712856bd832d373c20a6394a16de
doc_id: 314710
cord_uid: 4vwvnths

‘Superbugs: A Pop-up Science Shop’ was a public engagement event in the school summer holidays of 2019, organised by members of Cardiff University’s School of Medicine. We transformed an empty retail unit in the centre of Wales’ largest shopping centre into an interactive and immersive microbiology experience. We aimed to facilitate opportunities for two-way dialogue to impart positive impact on the awareness of antibiotic resistance, whilst concurrently evaluating the efficacy of an engagement strategy focused on the utilisation of public spaces to attract public demographics diverse to those who would normally engage with STEM outreach. Over the course of 14 days, we welcomed 6,566 visitors, with 67% attending as part of the natural footfall of the shopping centre. We created 1,625 young Antibiotic Resistance Champions, located in over 200 schools. Through a multi-lateral evaluation strategy, we were able to collect quantitative and qualitative feedback on the success of our delivery model, and the impact on our stakeholders. Herein, we will discuss the evolution of ‘Superbugs’ from concept, planning and design, to the logistics of delivering an engagement event of this scale. We will focus in particular on the learning outcomes of the project, and how this will shape the future of our ‘Superbugs’ project, and engagement events beyond. Key Messages Creating a multi-disciplinary core team is essential to the success of large-scale engagement events as well as the support and development of large numbers of colleagues/volunteers Utilising themes of exhibition and gameplay alongside strong fear-empowerment messages is an impactful way to confer positive influence and behaviour around antimicrobial resistance (AMR) and the use of antibiotics ‘Pop-up shop’ is an effective mode of delivery to capture diverse public demographics far beyond those who would traditionally engage with scientific outreach and science engagement.

we hoped to achieve in this project. As Carr In order to achieve this, we defined a number of underlying objectives; 158

To reach new and diverse public demographics by taking science to the people 159

To facilitate two-way dialogue of mutual benefit between scientists and the 160 public 161

To provide the public access to information about local and international AMR-162 related research, how it impacts their lives, and further scientific-public 163 engagement opportunities 164 (iv)

To create strategic relationships between Cardiff University, the public, and 165 supporting partners. 

From an early stage it was identified that a multi-skilled team from various backgrounds was 180 vital to delivering the project successfully. A core team was put together from across the School 181 of Medicine including AMR research scientists, public engagement champions and 182 professionals, and a graphic designer. The benefit of this to the project was not only the wide 183 spectrum of talents and knowledge, but also the network of contacts brought to the table by 184 each core team member. In addition to this, two early career researchers (ECRs) were recruited 185 to work with us in designing the AMR-related content, of which the shop would comprise. 186

Equally as important to the success of the project were the strategic partners with whom 187 we were able to engage. 

To inform the planning stages of the event, a focus group was organised for key target 208 stakeholders: families with children of Key Stage 2 (7-11 years old) and Key Stage 3 (11-14 209 years old). The event was held after school hours at Rhiwbina Primary School in Cardiff and 210 was attended by seven families recruited through an invitation forwarded onto parents by the 211

Headteacher of the school. Children were split up into two groups and taken through a number 212 of sample activities akin to what we hoped to deliver at the future event. Concurrently, we 213 facilitated a discussion with the parent on various aspects of the project, before eventually 214 coming together to gather further feedback from the children. This approach proved to be an invaluable step in the evolution of 'Superbugs', not only 217 by informing the final design schemes of the shop, but by also confirming that our planned 218 activities were engaging not only to our primary target stakeholders, but also by those younger 219 and older. To quote one inquisitive four-year old after attending the focus group, 'looking at 220 the little things in the microscope was my favourite'. 221 222 

Discussion points taken from our Focus Group session that played a key role in the evolution and direction of the 224 project.

• Overwhelming preference for a more colourful, less 'corporate' design and colour scheme, which will appeal more to families and young children • Make obvious the flexibility in how much time visitors need to spend on the experience • Use social media (increasingly influential for family units) The origin of the 'Superbugs' design lies in promotional material developed for the 236 Systems Immunity Research Institute including a bus poster campaign and social media 237 (https://www.cardiff.ac.uk/systems-immunity/about-us). Illustrations were created to represent 238 the diversity of micro-organisms that inhabit our bodies, adding intrigue to attract further 239 attention from the public. Acting on feedback from our focus group (Table 1) 

It is perhaps important to note that prior to the event, our promotional activities were minimal 288 by design, to maximise the sensitivity in measuring engagement from passers-by of our public 289 location. Firstly, we ran a minimal social media campaign, promoting our e-poster. In the week 290 leading up to the event we ran a short promotional campaign in Primary Times Cardiff & Vale 291

(https://www.primarytimes.co.uk/cardiff/) which involved advertising the event on social 292 media and featuring 'Superbugs' in their 'What's On' pages. An email with an e-poster 293 advertising the event was sent around to secondary and primary Schools in Wales that were 294 already in the engagement network of the School of Medicine through our 'Science in Health' 295 events (https://www.cardiff.ac.uk/medicine/about-us/engagement/science-in-health). In the 296 first few days of the live event, we carried out a leaflet drop at particular tourist and visitor 297 hotspots around the city centre, including the nearby library, museum, and information desks. 298 299

The Wellcome Trust 'Reframing Resistance Report' 301 (https://wellcome.org/sites/default/files/reframing-resistance-framing-toolkit.pdf) identified 302 the importance of how we approach AMR engagement; "How an issue is 'framed'-explained 303 and presented through specific themes and angles-can influence how it is received by an 304 audience". Informed by a multi-phase international research project, the report outlined a 305 'Framing Toolkit' identifying five principles in how AMR-communication and outreach 306 should be framed; (i) frame antimicrobial resistance as undermining modern medicine, (ii) 307 explain the fundamentals succinctly, (iii) emphasise that this is a universal issue; it affects 308 everyone including you. (iv) focus on the here and now, (v) encourage immediate action. In awareness. Subsequent studies revealed that combining a strong fear warning with messages 315 of empowerment for the stakeholders did in fact induce a positive response in a way that 'fear-316 only' and 'mild-fear-plus-empowerment' messages did not (Roope et al., 2020) , resulting in 317 patients being less likely to request antibiotics. The paper concluded that 'fear could be 318 effective in public campaigns to reduce inappropriate antibiotic use but should be combined 319 with messages empowering patients to self-manage symptoms effectively without antibiotics'. 320

These findings certainly reflect similar such conclusions from public campaigns in other areas 321 of healthcare science. 322

We adopted such approaches when designing the content of the 'Superbugs' shop. We 

It was decided early on in the project to avoid making any assumptions as to prior 338 knowledge of the topic of AMR on the stakeholders, as to not compromise our overall message. Questionnaires were completed by 10% (n=656) of visiting parties, which is 373 particularly impressive when taking into account that a significant number of our stakeholders 374 were family groups with, in many cases, one parent/child completing a questionnaire on behalf 375 of the whole family. Returning a completed questionnaire to the organisers was incentivised 376 by entry into a twice-daily prize draw, where the winners won a bag of 'Superbugs'-branded 377 prizes. Station 5 ('Create your own microbes') produced over 500 pieces of artwork, many of 378 which adorned the walls of the shop throughout the event and featured prominently in our 379 social media campaign. Over 300 items of activities and reading material were taken away 380 from Station 5 by visitors. At Station 4 ('Grow your own microbes') we generated 2,169 swab 381 plates, with the subsequent social media posts garnering over 2,500 views. 382

Owing much to these swab photos, our social media presence gained significant interest 383 

The event received a notable amount of local media attention. We were involved in a fun 465 feature on the 'Josh & Kally show' for Capital FM South Wales. The radio presenters were 466 invited to swab themselves live on air, and we returned the next day to deliver the results as to 467 who grew up the most microbes. This was a unique way to engage a young demographic in the 468 topic of bacteria and to inform wider groups about the ongoing 'Superbugs' event. The local 469 television station Cardiff TV spent over an hour in the shop filming visitors engaging with our 470 activities, and interviewing members of the 'Superbugs' team. Two videos were produced and 471

shown repeatedly across the local area for the remainder of the event and can be found at the 472 events homepage (https://www.cardiff.ac.uk/systems-immunity/engagement/understanding-473 science/superbugs-a-pop-up-science-event). 474

We were also able to raise interest and attention from high profile stakeholders 475 whole. We hypothesised that this mode of delivery would be successful in reaching a wide 492 demographic, beyond the limited cohorts who would typically seek out opportunities to engage 493 in scientific research. Questionnaire data collected showed that indeed 67.3% of entries were 494 impromptu visits with no prior knowledge of the event before spotting it on the concourse of 495 StD (Figure 8 ). This was significantly higher than those visitors indicating any awareness due 496 to aspects of our promotional campaign, including advertisement in the Primary Times magazine, website and social media. Whilst confirming our hypothesis, it was also a triumph 498 for the imaginative and imposing exterior designed by our team and informed by our focus 499 group. This also suggests that in future public space located engagement events, significant 500 resources may be better focused on providing the best and most attractive possible experience 501 for visitors, as opposed to an overly enthusiastic promotional campaign. 502

The importance of our focus group in shaping the nature of the content and the overall 503 design theme for 'Superbugs', and the impact this then had on the success of the event, 504

illustrates the potential in utilising focus groups, public involvement and co-production in 505 shaping such projects. We hope this leads to developing a culture of increased efforts for co-506 production and public involvement across the School of Medicines engagement activities, to 507 the benefit of the scientists and public alike. 508

Further confidence in our strategy was corroborated in the data collected through our 509 questionnaires (Table 2 ). 95% and 91.9% of visitors, respectively, agreed/strongly agreed that 510 the event was fun, engaging and informative, and that we had pitched the intellectual level 511 appropriately. We are very proud to say that over 94% of visitors indicated that they not only 512 rated 'Superbugs' as 'Very Good' or 'Excellent' but, perhaps even more significantly, they 513 would also recommend 'Superbugs: A Pop-Up Science Shop!' to others. 514 were invited from senior leaders, to explore this model of engagement, its potential for societal 521 change and how such activities can be sustained in the longer term. 522 523

We may assuredly accept the hypothesis that our pop-up shop was an effective way of 525 imparting positive impact on the AMR awareness of the public audience with whom we 526 engaged. Table 2 illustrates that 'Superbugs' improved the understanding of the world of 527 microbes, antibiotics (and how they work) and antibiotic resistance in 92.7%, 92.5% and 91.7% 528 of cases, respectively. Perhaps more significantly, our evidence supports a progressive 529 influence on future behaviour and attitudes towards antibiotic stewardship, with 90.8% of 530 participants now more likely to complete a full course of antibiotics. Improved antibiotic 531 stewardship has significant and far-reaching implications for our ability to control AMR 532 pathogens (File et al., 2014) 533 Secondary to this, we may infer far-reaching legacy impact of our event. 1,626 young 534 people left not only bestowed with the title of 'Antibiotic Resistance Champion' but also with 535 their certificate detailing tips on how they can further their knowledge and spread the word 536 long after the doors of 'Superbugs' had closed. As a testimony to the success of this approach, 537 91.3% of visitors completing the questionnaire stated they would pass on what they had learnt 538 at the event (Table 2) . 539 540 For the lead scientist, it was their first experience of independently securing grant funding, and 562 the organisational and administrative responsibilities that comes there-in. 563

Logistically, 'Superbugs' was a mammoth undertaking requiring staff to give up their 564 own time to take part. In total, 33 volunteers helped deliver aspects of the event, involving 5-6 565 individuals being present at the shop and facilitating the activities at any one time. Station 4 566 ('Grow Your Own Microbes') in particular required extra-curricular assistance in the 567 incubation, sorting and photography of all swab plates, and the subsequent uploading of the 568 anonymised photos onto a bespoke Facebook album. Volunteers were at various stages of 569 career and backgrounds across the academic spectrum; from professional staff, research 570 associates and senior academics, to students ranging from undergraduates to PhD, and for many 571 'Superbugs' represented their first experience of public engagement. On their first day of 572 volunteering, all were fully briefed on the content of the shop, and the concept and messages 573 behind each activity. Each day we attempted to provide a mixture of inexperienced 'engagers' 574 with more senior staff, in order to breed a supportive environment where communication skills 575 could be developed and enhanced. 576

As described, we saw an incredible response to our Station 5 'Grow your own microbe' 577 activity, where visitors were able to swab themselves and then using a unique code, follow up 578 on what grew at a later date online. The enthusiasm with which visitors engaged with this 579 suggests at a potential rich resource that could be exploited for research purposes and could 580 provide a unique insight into the social and environmental spread of target micro-organisms, 581 and the anthropogenic factors driving this dissemination. 

representing a diverse 695 range of approaches that have been implemented to this end, and in doing so highlights a most 696 pertinent point. Simply, in undertaking a systematic review of AMR-related engagement 697 activities, an intrinsic limitation was the relative paucity of publications based on such 698 activities. Indeed, there is a similar such problem for microbial literacy within the public and 699 education sectors also (Timmis et al., 2019) and this is further reflected in the Wellcome Trust's 700 'Reframing Resistance Report

Tyrrell is a Lecturer in Medical Microbiology and Antibiotic Resistance at the School of 708

As a passionate scientific communicator Jonathan became 709 involved in a number of engagement activities, leading to him creating 'Superbugs: A Pop-Up Science Shop

Jonathan was lead scientist on the 'Superbugs' and was responsible for the conception, and involved in all 711 following facets

Ms Christie Conlon is a professional graphic designer for Cardiff University's College of Biomedical & Life 713 Sciences and the BBC. Christie was the graphic artist of the project and was responsible for the design of the shop 714 interior, exterior, logos

Aboklaish is a research associate working on antibiotic resistance in the School of Medicine

Ali assisted in the administrative, planning and delivery of the project and was also a member of the 717 'Science content' team that designing the information and activities delivered

Sarah led on the 719 organisation of the project's focus group ensuring the project's target audience informed the development, 720 delivery and subsequent output of the proposed engagement activity

Mr Carl Smith is the Public Engagement Manager at Cardiff University. Carl was an advisor from the earliest 723 stages of the project and volunteered for the delivery of the event

Mr Jordan Mathias is a research assistant working in the field of antimicrobial resistance in the School of 725

Jordan was part of the 'Science content' team, designing the information boards 726 and activities within the shop

Ms Katy Thomson is a PhD student working in the field of antimicrobial resistance in the School of Medicine

Katy was part of the 'Science content' team, designing the information boards and activities 730 within the shop

Matthias was instrumental in the strategic design, 733 delivery and evaluation of 'Superbugs

We would like to thank all volunteers for their endless efforts in supporting the project from conception to 737 delivery, without whom the project would not have been possible

Further 742 thanks must go to Thomas Greaves of Morgans Consult, whose support in delivering the installation of the exterior 743 and interior design and fitting of 'Superbugs' was unwavering and beyond the call of duty

British Society for Immunology who provided important support to our grant application and to the event. Finally, 745 a thank you to GiantMicrobes ® for their generous provision of cuddly microbes to be used as display items

The project was specifically funded by a Wellcome Trust ISSF3 Public Engagement Proof-of-Concept Award

The project received further contingency support from the Systems Immunity Research Institute

Antibacterial Engine) of IMI's ND4BB, and grant NE/N01961X/1 of the Antimicrobial Resistance Cross Council 753 Initiative, supported by seven UK research councils

Improving the quality of antibiotic prescribing in the 757 NHS by developing a new Antimicrobial Stewardship Programme: Start Smart-Then Focus

Public Spaces

Providing evidence of impact from public engagement with research: A case study from the 761 UK's Research Excellence Framework (REF)

The Control of Methicillin-Resistant Staphylococcus aureus Blood Stream Infections 764 in England

Assessing the Knowledge, Attitudes and Behaviours of Human and Animal Health 766

Students towards Antibiotic Use and Resistance: A Pilot Cross-Sectional Study in the UK

A mixed methods pilot of Beat the Bugs: A community education 769 course on hygiene, self-care and antibiotics

Antimicrobial Stewardship; Importance for Patient and Public Health

The Antibiotic Guardian campaign: a qualitative evaluation of an online pledge-based 774 system focused on making better use of antibiotics

An internet-delivered handwashing intervention to modify influenza-like illness and 777 respiratory infection transmission (PRIMIT): a primary care randomised trial

Engaging with the public in public engagement with research

Implications of antibiotic use during the COVID-19 pandemic: 782 present and future

Will coronavirus disease (COVID-19) have an impact on antimicrobial 785 resistance?

The Novel Coronavirus COVID-19 Outbreak: Global Implications for Antimicrobial 787

Raising awareness of antimicrobial resistance among the general public in the UK: the 789 role of public engagement activities

A common standard for the evaluation of public engagement 791 with research

Reducing demand for antibiotic prescriptions: evidence 793 from an online survey of the general public on the interaction between preferences, beliefs and information

Reducing expectations for antibiotics in primary care: a 796 randomised experiment to test the response to fear-based messages about antimicrobial resistance

The urgent need for microbiology literacy in society

Global Action Plan on Antimicrobial Resistance

Antibiotic Resistance

including those of age, culture and religion. Enrolling Diverse Cymru as a strategic partner 596 provided us with an independent and judicious evaluation on how 'Superbugs' met the needs 597 of, and appealed to, people with protected characteristics, and ways in which we could improve 598 this even further for future activities. This was considered during the design of the shop layout, 599 ensuring information and activities were accessible for a range of heights and abilities, and 600 there was adequate space to accommodate mobility aids. Highlighted was the need to more 601 apparently cater for those with sensory, learning and cognitive impairments, primarily in some 602 of the language used at certain areas of the shop, and the prominence of instructions for our 603 activities. In addition to this, we are committed to applying decolonisation of all information 604 provided in future 'Superbugs' events, to reflect a more accurate, diverse and global view of 605 the topic area. This also highlights an intrinsic issue within the academic culture and attitudes towards 646 public engagement activities. Historically, public engagement may be seen simply as a way in 647 which to educate the 'scientifically illiterate'. As such, the discipline of public engagement has 648 been underserved in time, attention, funding, and willingness to participate (as evidenced here) 649 by academic institutions and the staff therein. Perhaps nothing more than a pleasantry aside to 650 the primary roles of researchers. This is further exacerbated by an environment that prioritises 651 quantifiable publications and grant funding in determining career prospects and progression. 652This apathy is somewhat counterintuitive given all science, at it's very foundation, is for the 653 betterment of the human condition and those we seem reluctant to communicate to. 654The introduction of 'impact' (encompassing public engagement) as an element of 655 assessment for REF 2014 is perhaps a clear signal of a slowly changing tide in this regard 656 (Copley, 2018) . Increasingly, public engagement may be seen as a tool to raise an institutes 657 profile, influence policy makers (both directly and indirectly) and further quantify research 658 impact. However, a paradigm shift in the way in which public engagement with research is 659 regarded at all levels of academia is still needed. More standardised frameworks for the design, 660 implementation and evaluation of public engagement activities are required to advance the 661 integrity and rigour of this capacious discipline, and there is a growing literature to achieve this 662 (Mahony and Stephansen, 2017) . Furthermore, as the demand for public engagement with 663 research activities continues to increase from funders, concern around recognition, value and 664 support amongst employers requires further exploration. 665 666

Currently, we as a society are facing the challenges of the COVID-19 pandemic. It would be 668 remiss however, to entertain any oversight of the more silent pandemic of AMR that has been 669 with us for decades and continues to carry severe impact economically and on public health. simply not possible at present, and not for the foreseeable future. In August 2020 we 684 successfully secured grant funding through the ISSF3 Public Engagement Co-production 685 award to co-produce a permanent online/digital website presence for 'Superbugs' and are 686 currently working with stakeholders from across the education sector, whilst designing and 687 delivering our co-production and evaluation strategies. Immersive and interactive events in 688 public spaces will continue to be at the heart of what we deliver with 'Superbugs', and we were 689 pleased that just before the arrival of COVID-19 in Wales, a first successful redelivery of select 690 'Superbugs' activities were run as part of Cardiff Science Festival in February 2020. 691Increasing public awareness around AMR and antibiotic use now forms a cornerstone 692 of the UK government's 20-year strategy in managing and controlling the issue 693 (www.gov.uk/government/publications/uk-20-year-vision-for-antimicrobial-resistance).