Our environmental scan shows that many organizations are working to develop and share course content and educational resources for HCW training and continuing education around the world. We identified several types of resources, from traditional in-person courses to workshops and conferences, to MOOCs, to online campaign materials, to handbooks, and to workbooks. Governments, hospitals, and professional societies appear to be driving action on this front, and these three types of organization have successfully built partnerships with others including non-profits, insurance companies, and WHO regional offices.
This level of collaborative work is promising; however, we have identified opportunities for action on several fronts. First, there is an opportunity for the development of better resources and training opportunities for students in the healthcare professions. Early engagement can provide a strong foundation of AMR knowledge that students draw upon as they progress through their careers as prescribers and patient educators. Second, it appears that training for current HCWs is probably under-recognized by professional development and continuing education programs. HCWs need to have their AMR learning efforts formally recognized, as they may lack incentives to engage in substantial additional training on a purely volunteer basis. Below we discuss how addressing these two elements of training, both pre-service and continuing education, can improve the content, delivery, uptake, and scale-up of AMR/AMS education, and identify programs that are interesting models for development of further resources.
Pre-service student engagement
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 . 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 . 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.
Other mechanisms of engagement
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.
Strengths and limitations of this study
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. .
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.