GADSA: gamified Antimicrobial Stewardship (AMS) decision support app for prescribing behaviour change

Lead Research Organisation: University College London
Department Name: Inst for Risk and Disaster Reduction


Antimicrobial resistance is a global problem. Implementing appropriate antimicrobial prescribing policies and stewardship in clinical and community healthcare settings is one of the powerful ways to reduce antibiotics overuse. This is of great importance in Nigeria and other Low and Middle Income countries (LMIC) where clinical practice is less regulated. In these countries, due to resource constraints, a widespread over the counter availability of antibiotics and counterfeits create a very challenging environment for implementing antimicrobial stewardship. The Infection Control Africa Network (ICAN), with 28 African member states, has launched the Antimicrobial Stewardship Education Initiative in July 2016 to tackle this issue across the continent.
The aim of this interdisciplinary project is to investigate the use of gamified apps on mobile phones and tablets for changing prescription rates through improving compliance with prudent antimicrobial prescription policies, supporting professionals in prescription decision making around three key conditions (urinary tract infections, single dose surgical prophylaxis and upper respiratory track infections). Based on previous study with ICAN and the international Infection Control Resource (iNRIC, www.nric,org,uk) delivering policies and guidance to infection professionals at the point of care, it was identified that African experts preferred accessing policies in a graphical gamified format over their mobile devices compared to text-based guidelines.
The app will be co-authored and developed jointly with healthcare professionals from two settings (national teaching hospital in Lagos and a community hospital) and evaluated to assess usability and prescribing behaviour change over a period of 3 months. The cutting edge game-based training technology will enable a customisation support to localize the gamified app to new settings by healthcare professionals themselves. This pilot will demonstrate a new innovation approach with a potential to be cost-effectively scaled up and expanded to cover other AMS policies and settings to support professionals across ICAN member states across the African continent.
Our multi-disciplinary team, consisting of computer scientists, epidemiologiest, infection control experts , and a behavioural scientist is ideally placed to develop an app based AMS intervention. We have expertise in app development, AMS guideline translation, and behaviour change, ideally placing us to deliver the proposed programme of work. Moreover, we will co-design our app with users in Nigeria, utilising our existing partnership with ICAN and The College of Medicine of the University of Lagos - affiliated to the national Lagos University Teaching Hospital (LUTH) and regional Obafemi Awolowo University hospital.

Planned Impact

Who will benefit from this research?
The research community around AMS, infection control, epidemiology, digital health, game-based training, behaviour change, evidence-based policy dissemination, update and compliance, surveillance and prescribing.
Patients will benefit directly by reducing their stay in hospitals, cost of care, cost of prescription enabling improved health outcomes.

How will they benefit from the research?
While the focus of this project is on Nigeria and our app will be developed / co-authored with local experts, the research is ultimately scalable across LMIC countries. We will develop a novel cutting edge customisation of the app design making it possible to localise the policy and artwork, language to your needs. This will pilot a long terms sustainable solution.
We will be also empower local professionals in terms of healthcare training and involvement in the design and co-authoring of the technology.
We will strengthen professional collaboration between the UK and Africa in a strategic domain of AMS and infection and aim to change prescription behaviour.
Long-term will be aim to change the rates of antibiotics prescribing

What will be done to ensure that they have the opportunity to benefit?
We will work very closely with the Nigerian team and with the volunteers conducting the evaluation. Will be use multiple channels to engage and raise awareness - iNRIC portal and app, eNewsletter, ICAN newsletter, ICAN 2018 Workshop to present the app, and other networks affiliated with iNRIC.

Academic publications in interdisciplinary conferences (ACM Digital Health, IFIC, ICAN, IPC, ECCMID, FIS, ESCAIDE, SEGAD, CBC, Foundation of Digital Games, Games for Health etc ) and journals (e.g. Frontiers in Digital Health, BJIC, Lancet, IJIC, JMIR, JAMIA, JAC, etc).

Most importantly, beyond this pilot project we have a long-term plan: with ICAN we plan to apply for strategic funding to expand the development of the app, cover a wider selection of AMS policies and deploy these in multiple countries. We plan to run a cluster randomised RCT to evaluate their effectiveness in changing AMS practise and prescribing behaviour. Linking the app to the hospital prescription system would be another step enabling direct e-prescribing at the point of care and seamless cost effective surveillance. This is a highly impactful project with the potential to reduce prescribing across Africa over the next decade!
Description The project team decided to focus on AMR for surgical site infections (SSI). We have investigated behavior barriers and situational analysis with regards to AMR compliance in Nigeria, developed a gamified decision support app piloted at the point of care in 3 hospital sites with over 60 surgeons recording around 300 prescription decisions and their change as a result of the advice given by the app. We demonstrated increased compliance with the WHO and Sanford guidelines, behaviour change at the point of care reducing unnecessary prescribing and the need for a local guidelines appropriate for low income settings. The project was awarded a number of awards and prizes.
Exploitation Route GADSA developed an innovative, first of its kind, app for decision support used at the point of care demonstrating behaviour change for SSI prescribing in surgeons that could be scaled up for other AMR policies and other countries across Africa and developed world. It contributes to the global fight against antibiotic resistance.
Sectors Digital/Communication/Information Technologies (including Software),Healthcare

Description This innovative project demonstrated direct impact on prescription behaviour for AMR prescribing in surgeons in Nigeria at the point of care. This is the first decision support app demonstrating behaviour change sucess of its kind. The long term vision is to scale up the solution to support AMR stewardship in the continent and globally.
First Year Of Impact 2019
Sector Digital/Communication/Information Technologies (including Software),Healthcare
Impact Types Societal,Economic,Policy & public services

Description EPSRC IAA Discovery-To-Use
Amount £14,676 (GBP)
Funding ID KEIF 2017-20 (B1.27) 
Organisation Engineering and Physical Sciences Research Council (EPSRC) 
Sector Public
Country United Kingdom
Start 05/2019 
End 11/2019
Description Adaptation of GADSA technology for DR-TB decision support 
Organisation University College London
Department Institute For Global Health
Country United Kingdom 
Sector Academic/University 
PI Contribution Co-writing of successful grant to adapt GADSA technology for development of DR-TB decision support tool
Collaborator Contribution Co-writing of successful grant to adapt GADSA technology for development of DR-TB decision support tool
Impact Multidisciplinary partnership: Computer Science, Behavioural Science, Global Health, Infection Control, Medicine Successful research proposal for GCRF funding
Start Year 2019
Description The International Pharmaceutical Federation 
Organisation The International Pharmaceutical Federation
Country Netherlands 
Sector Learned Society 
PI Contribution collaboration with FIP started in 2019 and ways of joined future research have been investigated
Collaborator Contribution support and endorsement - exploring future collaboration
Impact multidisciplinary collaboration with the world largest society for pharmacists has been initiated and initial steps (such as presentation to their Digital Team and management) have been taken. No results to report yet.
Start Year 2019
Title specification of new gamified AMR app 
Description this is work in progress app and back end development to implement SSI AMR policies 
Type Of Technology Webtool/Application 
Year Produced 2018 
Open Source License? Yes  
Impact too early to define impacts but the long term vision, when the project is completed, is to have the app deployed and scaled up 
Description Invited talk at 7th Infection Control Network Congress 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact PK gave an invited talk at the 7th Infection Control Network Congress in Cape Town, South Africa. The talk prompted discussion and questions from the audience and led to further discussion afterwards. The talk led to ongoing working relationship with colleagues in Africa and ongoing work with the Infection Control African Network enabling progression of GADSA project work and evaluation of its impact on prescribing behaviour change.
Year(s) Of Engagement Activity 2019
Description Poster presented at IRDR Conference 2018 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Postgraduate students
Results and Impact Poster presentation given at the UCL IRDR annual conference in 2018. The presentation prompted discussion amongst the conference audience with interest in finding out more about the project. Following the presentation, we were able to organise several meetings with new UCL-based colleagues to discuss expansion of the GADSA project work across Africa.
Year(s) Of Engagement Activity 2018