Pathways, Practices and Architectures: Containing Antimicrobial Resistance in the Cystic Fibrosis Clinic (PARC)

Lead Research Organisation: University of York
Department Name: Sociology

Abstract

Antibiotics may suppress infections without eliminating them, giving rise to antimicrobial-resistant (AMR) bacteria and cross-infection between people. This project is both timely and important because of the increasing numbers of bacteria acquiring resistance to existing antibiotics. Our research compares the way three outpatient lung infection clinics attempt to control AMR and cross-infection through the design, practices and architectural layout of their built environments. It further seeks to learn lessons from this to limit AMR in wider healthcare settings.

The PARC project has been co-designed in close collaboration with our three partner cystic fibrosis (CF) clinics. CF is just one of many life-threatening conditions characterised by long-term antibiotic treatment giving rise to cross-infection. In turn, cross-infection leads to clusters of highly resistant bacteria which significantly reduce life expectancy and now threaten to reverse recent improvements in survival.

Dialogue with our clinical partners highlights the very different material and design approaches taken to prevent cross-infection through physical isolation, segregation and containment. Despite these variations, detailed research into questions of design and practice within the built environment of respiratory clinics is sparse. This research will be significant because CF clinics have much to learn by reflecting on their own practices. They also have much to learn from each other, and much to offer the wider clinical community in limiting AMR. Our focus on CF as an exemplar has far broader relevance in design approaches to AMR mitigation in more common respiratory disorders and in infection control more generally.

This research will make visible the different and sometimes competing AMR design priorities of key stakeholders (including people with CF, clinicians, designers, hygiene personnel, etc.). It will map the differing 'real world' pathways and journeys through each clinic. It will explore how physical interaction, contact and exchanges are managed through the layout of the clinics. It will also enable our partner clinics and their users to explore scope for redesigning practice and repurposing clinical space to limit AMR and cross-infection.

Our project involves an innovative combination of visual and qualitative research methods. We will be using the architectural layout plans of each clinic as a focus for interviews with patients, clinicians, hospital estates personnel, hygiene staff and designers. Our interviews will also draw on the skills of the project's graphic artist who specialises in fieldwork illustration to visually record real world experiences and journeys. We will also be undertaking 'walking interviews' placing our respondents within the flow of their routines, and using photography to chronicle risky spaces and objects. The project has an observational component to document key sites of high risk within the clinics including waiting areas, reception desks, corridors, wash basins and hand sanitisers, etc. These visual, graphic and textual findings will subsequently be used in co-design workshops at each of the clinics to improve present and future AMR mitigation.

The project brings together the expertise of a highly multidisciplinary team involving an academic architect, sociologists of medicine and science, micro-biologists and a graphic artist. PARC will have a positive impact upon: our three partner clinics who have been involved in the design of the project; people with CF and the CF Trust; the wider respiratory healthcare community, the NHS and Department of Health; healthcare designers and architects; policy making on AMR.

Planned Impact

PARC is designed to have a direct benefit for our partner clinics in addition to broader influence in healthcare.
1. CF Clinics (Project Partners): Our partner clinics have been closely involved in PARC's study design to ensure findings shape future practice. The project will have impact through the active collaboration of the clinics within each of the 3 Work Packages and the drafting of 3 interim reports. Complete reports including a confidential annex (2 pages) will be discussed at each of the clinics and formulated to feed directly into their Health Care Associated Infection Reduction Plans. Portable Project Poster Presentations will present core findings and visual data (Chapman's interview illustrations, layout plans, etc.) providing a focus for redesign options in WP 3 at each clinics, and subsequent impact and dissemination (see below). Interim reports: 'Spaces and Practices - mitigating anti-microbial resistance (AMR) in the outpatient clinic' (month 12); 'Pathways, Journeys and Flow - mitigating anti-microbial resistance (AMR) in the outpatient clinic' (month 18); 'Imagining Redesign - mitigating anti-microbial resistance (AMR) in the outpatient clinic' (month 21).
2. Respiratory healthcare and infection control stakeholders: CF as an exemplar has broader relevance in design approaches to AMR-mitigation for more common respiratory disorders. Respiratory clinics face multiple design challenges exacerbated by existing floor plans, entrenched practices, the age of buildings, and communication barriers between designers and end users. By defining and sharing creative design ideas, CF clinics have much to learn from each other, and much to offer the wider clinical community in limiting AMR. In order to achieve wider impact we will register for presentations at clinical conferences including the British Thoracic Society (BTS) and the Federation of Infection Societies Conference (FISC). The Cystic Fibrosis Trust has agreed that we present at their Annual Conference in addition to other events (see letter of support from CF Trust). We will present the project's aims and findings to clinical workshops at our partner CF clinics and create opportunities to present to other CF/Respiratory clinics nationally.
3. Healthcare architectural design stakeholders: The project is designed to have impact within the healthcare architectural community who are increasingly tasked with taking infection control into account. Impact will be achieved through networking and dissemination to bodies such as, for example, Architects for Health (AfH) and the Royal Institute of British Architects (RIBA). Our Project Advisory Group includes the senior architect for P+HS Architects Limited and the lead designer of Nottingham's Wolfson Cystic Fibrosis Centre.
4. Project Advisory Group: the PAG will serve as a means of embedding impact into the project, providing input into the production of dissemination activities, and extending PARC's influence (See Pathways to Impact)
5. The Stakeholders' Forum will take place at the end of the project comprising round-table workshops generating feedback and input into key findings, highlighting aspects of innovative AMR-mitigation design transferable to broader settings (n40 participants).
6. Planned Non-academic publications: The team routinely publish and contribute to non-academic audiences (see Pathways to Impact).
7. Additional funding for impact and follow-on research: A number of strategies are in place to ensure new and added value of PARC. We will apply to UoY's £5m WT funded Centre for Future Health (2017-2022) for KIT (Knowledge Exchange, Impact and Translation). PARC has been designed to pump-prime further interdisciplinary research on AMR in the wider built environment by collaborating with our microbiology and clinical partners.
8. PARC Project website: platform for dissemination of good AMR mitigation practice including project presentations and interviews with researc
 
Title Pre-antibiotic, antibiotic and post-antibiotic: the co-design of an exhibition (PAD) - funded by the University of York and Wellcome Trust Centre for Future Health 
Description Objectives The objectives of the PAD project were to design and develop a physical and virtual exhibition to visualise and communicate findings from the PARC project, and to encourage knowledge exchange across different audiences (architects and designers, CF clinicians and other healthcare practitioners, researchers, patients and families). A key challenge was creating an exhibition that is accessible to people living with CF, in light of cross infection issues which mean they are unable to attend a physical exhibition. The virtual version of the exhibition enables us to communicate the project findings to people living with CF, and translate them to a wider audience. The exhibition highlights how practices of segregation and infection prevention vary across clinics, and over time historically. The exhibition aims to facilitate dialogue around current design and practice, and explore potential for change, drawing on past, present and future examples of design for mitigating cross infection and AMR. Both the real and virtual exhibition include building models of CF clinics and hospitals for infectious diseases. The models illustrate movement and flows through these buildings using pathway animations, and highlight key design features or challenges through vignettes and examples from the PARC research. Physical exhibition The physical exhibition included two building models onto which pathway animations of flows, and quotations and visual images from the research were projected. Lynne Chapman's artwork was integrated within these animations, and her concertina sketchbooks were also displayed separately as part of the exhibition. The exhibition included a backdrop displaying questions and issues for discussion, where visitors were encouraged to add post-it notes, sharing their own experiences. Lynne also sketched 'live' next to the exhibition, to capture discussions, and draw visitors to the stand. The exhibition was presented at key events across the UK and has been seen by an estimated 2000 visitors combined. These were: 1. European Cystic Fibrosis Society Conference (ECFS) 2. South West Network for Medical Humanities Regional Event 3. British Sociological Association (BSA) Medical Sociology Conference 4. The Helen Hamlyn Research Symposium 2019, Royal College of Art 5. Social Research Association (SRA) Annual Conference Research Gallery at the Royal College of Physicians. 
Type Of Art Artistic/Creative Exhibition 
Year Produced 2019 
Impact Visitors to the exhibition included: cystic fibrosis clinicians (nurses, physiotherapists, consultants), relatives of people living with CF, representatives of third sector organisations, designers, microbiologists, researchers and academics. The exhibition acted as a prompt for discussion, encouraging visitors to share experiences, and describe similarities or differences from their own CF clinics. Participants commented on the way the models helped to visualise the spaces and interactions in the research, through the use of pathway animations. As one visitor (historian) to the stand said, architectural plans can be 'difficult to interpret' and the models 'really help bring the building plans to life'. Another visitor (medical sociologist) remarked that it is 'it is far more powerful to see the findings in a visual way'. 
 
Description Significant new knowledge generated;

In a number of research outputs and papers, both published and in development, the project has generated new insights on the spatial and architectural dimensions of antimicrobial resistance (AMR):

- Whereas most social science engagement with AMR has focussed on aspects of 'behaviour' (prescribing, antibiotic usage, patient 'compliance', etc), our findings locate AMR in the context of building design and healthcare architecture, focussing on the layout, design and ritual practices of three cystic fibrosis (CF) outpatient clinics.

- Preventing AMR and cross-infection is taken to be a matter of the spatiotemporal isolation of both people and pathogens. Our research brought to the fore the role of the built environment exploring how containment and segregation are varyingly performed in interaction with material design.

- These include, first, aspects of flow, movement and the spatiotemporal choreography of CF care. Second, the management of waiting and the materiality of the waiting room is a recurrent concern in our fieldwork. Finally, we take up the question of air, the intangibility of air-borne risks and their material mitigation in the CF clinic.

Key themes explored and reported in our final report of the project included: segregation and cohorting; entrances and arrivals; architectures of interaction; circulation spaces; waiting; flows and movement; handwashing; air, atmospheres and window design; storage, fittings and equipment.


New or improved research methods or skills developed;

The PARC Project used a range of qualitative research methods, including ethnographic and innovative visual approaches. Fieldwork took place across 3 CF clinics between September 2018 and August 2019. It included the development of a physical and virtual exhibition and the dissemination of findings in bespoke co-design workshops across fieldwork sites.

Fieldwork for the project included: 70 interviews with 55 participants (some took part in both graphic and walking interviews) - 34 hospital staff, 15 patients, 3 family members, and 3 architectural professionals; 45 graphic interviews - mapping routes through buildings and perceptions of 'risky' areas; 25 walking interviews - following the routes of staff and patient; 72 hours of targeted observations observing 'flows' of staff, patients and equipment during clinics; 3 co-design workshops - presenting our findings and exploring potential for change with each of the 3 clinics; Sketch reportage - artist: Lynne Chapman created in-situ illustrations of patient and staff interviews and walk arounds.

Important new research resources identified;

The PARC project led to further funding from the University of York/Wellcome Trust funded Centre for Future Health for a physical and virtual exhibition presenting our findings, in collaboration with the Helen Hamlyn Centre for Design (HHCD), Royal College of Art (RCA), presented at: European Cystic Fibrosis Society Conference (ECFS); South West Network for Medical Humanities Regional Event; British Sociological Association (BSA) Medical Sociology
Conference; The Helen Hamlyn Researce Symposium 2019, Royal College
of Art; Social Research Association (SRA) Royal Annual Conference Research Gallery at the Royal College of Physicians; PARC's final stakeholder event held in January 2020 in York.
Exploitation Route Key elements of our findings were deliberated at each of our clinical study sites (sites 1, 2 and 3) during concluding 'co-design' sessions. In each case, this led to a concrete schedule of potential design interventions to be pursued in the immediate to medium term. In one case (site 1), this has involved working with the CF clinical team and a healthcare architect to input into the relocation of the outpatient clinic in order to optimise the best use of the new space.

The PARC project has led directly to new directions involving ongoing discussions with CF clinical, microbiological and academic partners to exdend PARC's scope. One example of this is a new collaboration with colleagues at the University of Ulster to extend PARC's methods and findings from the hospital/healthcare sector to the domestic environment, and the question of CF within the home environment.

We are also collaborating with colleagues at the University of Exeter, and CF patient advocacy partners, to extend PARC's findings through an application for further Wellcome Trust public engagement funding.
Sectors Healthcare

URL http://parcproject.org.uk/publications/
 
Description PARC was designed to have a direct benefit for our partner clinics in addition to broader influence in healthcare. 1. CF Clinics (Project Partners): The clinics were closely involved in PARC's study design and have directly benefitted already through the opportunities for critical reflection on their built environment (layout, practices and building design) afforded through the project. Formal group and individual interviews have been important opportunities for identifying potential improvements to clinical service including interventions in the direction and flow of people and equipment through the buildings to prevent cross-infection, etc. This was further developed through co-design workshops conducted at the end of the project - and captured in the Findings report. 2. Respiratory healthcare and infection control stakeholders: CF as an exemplar has broader relevance in design approaches to AMR-mitigation for more common respiratory disorders. Respiratory clinics face multiple design challenges exacerbated by existing floor plans, entrenched practices, the age of buildings, and communication barriers between designers and end users. By defining and sharing creative design ideas, CF clinics have much to learn from each other, and much to offer the wider clinical community in limiting AMR. In order to achieve wider impact we presented both an oral paper and an interactive exhibition at the European Society for Cystic Fibrosis annual conference in Liverpool, June 2019. We collaborated with our partners at the Royal College of Art Helen Hamlyn Centre for Design in the preparation of the exhibition and its online/interactive elements. 3. Healthcare architectural design stakeholders: The project was designed to have impact within the healthcare architectural community who are increasingly tasked with taking infection control into account. We met with, on a number of occasions, senior partners at P+HS Architects Limited who have led the design of lung infection clinics including Nottingham's Wolfson Cystic Fibrosis Centre. We have facilitated their input into the relocation of outpatient CF services at one of our research sites (site 1). 4. Project Advisory Group: the PAG served as a means of embedding impact into the project, providing input into the production of dissemination activities, and extending PARC's influence. This included representation from the UK Cystic Fibrosis Trust with whom we have also met separately to plan impact and engagement activities further into the project. 5. We conducted a final Stakeholders' Forum comprising round-table workshops generating feedback and input into key findings, highlighting aspects of innovative AMR-mitigation design transferable to broader settings (n40 participants). 6. Additional funding for impact and follow-on research: A number of strategies were proposed are in place to ensure new and added value of PARC. We applied to, and were successful, in securing additional funding from the UoY's £5m Wellcome Trust funded Centre for Future Health (2017-2022) for KIT (Knowledge Exchange, Impact and Translation). This resulted in our £57.2k award to underpin our collaboration with the Royal College of Art Helen Hamlyn Centre for Design. 7. PARC Project website: project outputs including our interim and final reports can be found here.
First Year Of Impact 2019
Sector Healthcare
Impact Types Cultural,Societal,Policy & public services

 
Description Architectures for a post-antibiotic age: the co-design of an exhibition
Amount £57,208 (GBP)
Funding ID NA 
Organisation University of York 
Sector Academic/University
Country United Kingdom
Start 09/2018 
End 09/2019
 
Description Architectures for a post-antibiotic age: the co-design of an exhibition - collaboration between the PARC project and The Helen Hamlyn Centre for Design/ Royal College of Art 
Organisation Helen Hamlyn Trust
Country United Kingdom 
Sector Charity/Non Profit 
PI Contribution Working collaboratively with the Helen Hamlyn Centre for Design (HHCD), at the Royal College of Art (RCA), we will stage an exhibition to raise awareness about the interconnectedness of building design and infection, and to create a space for dialogue between designers, architects, clinicians, patients, health care managers and the public. Using innovative inclusive design methodologies, this interactive event will be staged in 2019 initially at the annual conference of the European Society for Cystic Fibrosis. The exhibition, 'healthcare architecture in the pre-antibiotic, antibiotic, and post-antibiotic ages' will use in situ and virtual media to ensure inclusive access for patients, including those with CF. It will also be used as input into our participatory co-design workshops within CF clinics. Exhibition interactive resources will be designed so that they are available for CPD of architects beyond the life of the project.
Collaborator Contribution Design of the exhibition and all associated media: The partner has appointed an RA with a background in design through the highly competitive annual HHCD RA scheme. The scheme structures the fellowships using a 'double diamond methodology' comprising four equal phases as follows: Discover phase (September 2018 - November 2018). The RA works with the PARC team to familiarise him/herself with historical architectural resources (work package 1 of PARC) and access anonymised interview data illustrating key architectural and spatial challenges in the clinical management of infectious disease and AMR-mitigation. Define phase (December 2018 - February 2019). Clarification of the concept for the exhibition, scoping of visual and interactive media that can work best for the presentation of architectural materials in conjunction with qualitative interview and observational data. Participatory engagement to ensure input of key stakeholders. Develop phase (March 2019 - May 2019). Operationalisation, prototyping and construction of the exhibition. Regular liaison with the PARC team, and the three clinical leads at our partner clinics. Deliver phase (June 2019 - September 2019). Stage exhibition - Generate feedback to inform further refinement of the exhibition. Installation of exhibition. It should be noted that the format will be both in situ and remote/digital media to facilitate inclusivity of CF patients. The exhibition design must have both broad appeal yet crucially be accessible to a wide range of stakeholders, including people with cystic fibrosis taking into account their cross-infection vulnerability at public events. This exhibition will also be used as a catalyst for the re-imagining design work package of the PARC project (WP3 led by PARC CI Lewis).
Impact Exhibition at the European Society for Cystic Fibrosis Annual conference - Liverpool - June 2019 Pathways, practices and architectures - innovation in design and practice for mitigating cross infection in cystic fibrosis clinics Our exhibition explores innovations in the design and practices of cystic fibrosis clinics, in relation to mitigating cross infection and antimicrobial resistance (AMR). Practices of segregation which aim to mitigate cross infection are not standardised, and vary between clinics in the UK, with wider variation across Europe. Building design can enable - or inhibit - new possibilities for reducing cross infection risks in this context. These issues are presented through an innovative multimedia experience using 3D building models, projections, and sketch illustrations. The exhibition explores current design and practices in examples of UK cystic fibrosis clinics, and future areas for design innovation, incorporating viewpoints and experiences from key stakeholders such as patients, clinical staff, infection prevention personnel, architects and designers etc. The ideas are drawn from a UK research project Pathways, Practices and Architectures: Containing Antimicrobial Resistance in the Cystic Fibrosis Clinic (PARC), conducted by the University of York in collaboration with the Helen Hamlyn Centre for Design (HHCD), Royal College of Art (RCA). PARC is a multidisciplinary project, incorporating the perspectives of sociologists, microbiologists, architects, artists and designers, see: http://parcproject.org.uk/. We are conducting in-depth case study research at UK cystic fibrosis clinics, using qualitative and creative methods. Drawing on this research, the exhibition will facilitate knowledge exchange and dialogue between clinicians, designers and service users promoting the sharing of ideas for good practice, and areas for change. It presents opportunities for interactive engagement, aiming to stimulate ideas for future clinic design, and directions for further research.
Start Year 2018
 
Description Nik Brown (Co-I) 2019-2021. A liveable post-antibiotic future: Redefining the problem of antibiotic resistance from the perspective of social relations, working life and healthcare; Funded by the Pufendorf Institute for Advanced Studies at the University of Lund, Sweden 
Organisation Lund University
Country Sweden 
Sector Academic/University 
PI Contribution This is a network collaboration between partners at the University of York UK and Lund (Sweden)
Collaborator Contribution This theme interrogates the realities and imaginings of the post-antibiotic era, by investigating possible futures for a more liveable and sustainable relationship to antibiotics, to infections and to social life. Brown and Nettleton were listed as an international collaborator on the theme application to the Purfendorf Institute for Advanced Studies. The contribution of Brown and Nettleton includes residencies at the Institute (1 month in the case of Brown) plus participation in associated workshops, conferences, fieldwork and outputs.
Impact Still in development...
Start Year 2019
 
Description Presentations (x3) to each of our three partner lung infection clinics - attended by about 40 healthcare practitioners in total - to introduce the project and discuss further development. 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact The purpose of the presentations was to outline the methodology of the project, its key questions and intended outcomes - and to answer questions for our three collaborating lung infection clinics.
Year(s) Of Engagement Activity 2018
 
Description Buse, C., Brown, N., Nettleton, S., Martin, D. and Lewis, A. (2019) Infection prevention in cystic fibrosis clinics: interventions in design and practice, Healthcare Estates Conference, 8th-9th October 2019, Manchester. 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact The conference is one of the largest gatherings of healthcare estates professionals in the world - including 250 exhibitors and 4500 attendees.
Year(s) Of Engagement Activity 2019
URL https://www.healthcare-estates.com/healthcare-estates-conference-2019/
 
Description Co-design sessions (x3) at each of the project's three study sites (confidential) conducted during November and December 2019 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact Buse, Brown and Lewis presented study findings at a concluding co-design session at each of the 3 study sites. This included opportunities for participants to reflect on the findings of the study at each site and to consider various initiatives and possibilities for re/design interventions. These initiatives were outlined in the project's interim findings document made available at each of the three co-design sessions - and then further elaborated in the project's final concluding project report document.
Year(s) Of Engagement Activity 2019
 
Description Exhibition: Visualising infection prevention: Sketching stories, materialites and spaces in the cystic fibrosis clinic. Social Research Association (SRA) Royal Annual Conference Research Gallery, 10th December 2019, Royal College of Physicians, London. (curated by Sarah Nettleton and Daryl Martin) 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Other audiences
Results and Impact The event was an opportunity to showcase the visual methods (artwork and sketchbooks based on patient interviews and other fieldwork) deployed in the project. Dissemination of findings and demonstration of visual methodological approaches.
Year(s) Of Engagement Activity 2019
URL https://the-sra.org.uk/SRAConference2019/Programme-/Research%20Gallery/SRAConference2019/Research%20...
 
Description Invited presentation to the 'Pint of Science' public engagement event, the Eagle and Child pub, York. Title: Bugs, bodies and architecture: building for the 'post-antibiotic age' 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Public/other audiences
Results and Impact Special event organised as part of the Pint of Science festival - 2hr discussion based on the PARC project.
Year(s) Of Engagement Activity 2018
 
Description Nik Brown presented a 15 minute talk on the PARC project as part of the Annual York Talks event - a major platform for engagement and dissemination for the UoY's research. Title: Bodies, bugs and hospital architectures: Designing healthcare for the post-antibiotic age. 8thJanuary 2020 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Over 200 members of the public and the UoY community attended the event sparking debate and discussion around hospital design, architecture and antibiotics. The talk is available on Youtube.
Year(s) Of Engagement Activity 2020
URL https://www.youtube.com/watch?v=YCz7QUxdcs0
 
Description PARC team - 18th Sept 2018 - Poster presentation at the concluding conference of the 'Buildings in the Making' project (ESRC). 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact This was the concluding conference of the ESRC 'Buildings in the making conference' at which we presented the PARC poster.
Year(s) Of Engagement Activity 2018
 
Description Pathways, Practices and Architectures: Containing Antimicrobial Resistance in the Cystic Fibrosis Clinic, PARC Stakeholder Event, 23rd January 2020, York Railway Museum Conference Centre. 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Patients, carers and/or patient groups
Results and Impact Conference attended by 28 people, including architects, CF Trust representatives, family members of people with CF, patient representative, practitioners (nurses, physios), microbiologists, sociologists.

Conference attended by 28 people, including architects, CF Trust representatives, family members of people with CF, patient representative, practitioners (nurses, physios), microbiologists, sociologists. The event included a co-design workshop to facilitate general principles of hospital and healthcare architectural design for better infection containment.

The event included the launch of the project 40 page final report. It also included a physical exhibition combining an exhibition designed in collaboration the Helen Hamlyn Centre for Design / Royal College of Art. Additionally, the event exhibited all of the artwork produced by our project partner, the artist Lynne Chapman.
Year(s) Of Engagement Activity 2020