‘Superbugs’: raising public awareness of antimicrobial resistance through a pop-up science shop

Multidisciplinary team and strategic partners

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

Equally important to the success of the project were the strategic partners that we were able to engage:

• St David’s – the largest shopping centre in Wales, based in the heart of the Welsh capital, Cardiff, with a footfall of approximately 750,000 per week. Management staff from St David’s were involved in very early discussions about the viability of providing an empty unit within the centre, and they provided support to our funding application on those grounds.

• Morgans Consult – local signage and brand implementation specialists (https://morgansconsult.com/). Funding freed up by St David’s was invested in further professional delivery of both the interior and exterior of the pop-up shop. Morgans Consult worked closely with the team to design and fit an exhibition bespoke for the retail space provided by St David’s.

• Diverse Cymru – the only charity in Wales that focuses on all protected characteristics, to challenge discrimination and reduce inequality. Diverse Cymru provided us with an independent review, evaluating the performance of ‘Superbugs’ in meeting the needs of, and appealing to, stakeholders with protected characteristics.

• British Society for Immunology – provided enthusiastic support for the original application and project, alongside the promise of promotional and educational material for distribution at the event.

Focus group for target stakeholders

To support and inform the planning stages of the event, a focus group was organised for key target stakeholders: families with children in Key Stage 2 (7–11 years old) and Key Stage 3 (11–14 years old). The meeting was held after school hours at Rhiwbina Primary School, Cardiff, and it was attended by seven families recruited through an invitation forwarded to parents by the head teacher of the school. Children were split into two groups and taken through several sample activities akin to what we hoped to deliver at the ‘Superbugs’ event. Concurrently, we facilitated a discussion with the parents on various aspects of the project, before eventually coming together to gather further feedback from the children. Box 1 summarises the discussion points taken from this focus group session, which played a key role in the evolution and direction of the project.

This approach proved to be an invaluable step in the evolution of ‘Superbugs’, not only by informing the final design schemes of the shop (and the popular visuals of microorganisms), but also by confirming that our planned activities were engaging not only to our primary target stakeholders, but also to those younger and older. To quote one inquisitive 4 year old after attending the focus group, ‘looking at the little things in the microscope was my favourite’.

Design concept and the importance of exterior design

A fundamental aim of ‘Superbugs’ was to evaluate the effectiveness and success of a pop-up shop in engaging lay stakeholders of all demographics, not limited to those who would traditionally seek out events related to science, technology, engineering and mathematics (STEM). Attracting the natural footfall in the public location of the shop was therefore imperative, and the investment of the project’s time and finance in the exterior design of the shop reflected this. Figure 2 shows representative photographs taken before the transformation of the vacated retail unit (previously a Clarks shoe shop, with shelving and lighting still in place), and during the ‘Superbugs’ event, to illustrate the changes to the interior and exterior design of the shop.

Transformation from empty retail unit to ‘Superbugs: A Pop-up Science Shop’ (Source: Authors, 2022)

The origin of the ‘Superbugs’ design lies in promotional material developed for the Systems Immunity Research Institute, including a bus-stop poster and social media campaign (Systems Immunity Research Institute, n.d.). The illustrations were created to represent the diversity of microorganisms that inhabit our bodies, adding intrigue to attract further attention from the public. Acting on feedback from our focus group (see Box 1), the design was overhauled for the purpose of ‘Superbugs’, using brighter colours with the aim of attracting a younger audience, and enlarged to create a range of super-sized ‘Superbugs’. Strategically, the ‘Superbugs’ unit was well placed within St David’s. It was located directly opposite the Apple Store, within sight of other major retail units, such as John Lewis. Additionally, we were situated around the corner from the major family-friendly food quarter of the shopping centre, and close to the access point of the centre’s crazy golf site, during the summer holidays. All of this guaranteed a good level of natural footfall, ensuring that our large and colourful exterior design (Figure 2) had great visibility throughout the central concourse of St David’s.

Promotion of ‘Superbugs’

It is important to note that prior to the event, our promotional activities were limited compared with other engagement activities in the university, in part to maximise the sensitivity in measuring engagement from passers-by of our public location. First, we ran a simple social media campaign promoting our e-poster. In the week leading up to the event, we ran a short promotional campaign in Primary Times Cardiff & Vale (https://www.primarytimes.co.uk/cardiff/), which involved advertising the event on social media and featuring ‘Superbugs’ in their ‘What’s On’ pages. An email with an e-poster advertising the event was sent to all secondary and primary schools in Wales that were already in the engagement network of the School of Medicine through our ‘Science in Health’ events (Cardiff University School of Medicine, n.d.). During the first few days of the event, we carried out a limited leaflet drop of one thousand flyers at tourist and visitor hotspots around the city centre, including the library, museum and information desks.

Scientific content

The Wellcome Trust (n.d.) Reframing Resistance report identified the importance of approaching AMR engagement in terms of how the way an issue is ‘framed’ – explained and presented through specific themes and angles – can influence how it is received by an audience. Informed by a multi-phase international research project, the report outlined a ‘Framing Toolkit’ identifying five principles for how AMR communication and outreach should be framed: (1) frame antimicrobial resistance as undermining modern medicine; (2) explain the fundamentals succinctly; (3) emphasise that this is a universal issue – it affects everyone, including you; (4) focus on the here and now; and (5) encourage immediate action. Coordinating these frames is likely to create communication that informs, motivates and persuades.

Roope et al. (2017) have demonstrated that a message of warning on the dangers of AMR was not successful in imparting a positive influence on either the public’s attitude or practice in requesting unnecessary antibiotics, particularly in cohorts with low AMR awareness. Subsequent studies revealed that combining a strong fear warning with messages of empowerment for the stakeholders did, in fact, induce a positive response in a way that ‘fear-only’ and ‘mild-fear-plus-empowerment’ messages did not (Roope et al., 2020), resulting in patients being less likely to request antibiotics. The paper concluded that ‘fear could be effective in public campaigns to reduce inappropriate antibiotic use but should be combined with messages empowering patients to self-manage symptoms effectively without antibiotics’ (Roope et al., 2020). These findings certainly reflect similar such conclusions from public campaigns in other areas of health-care science.

We adopted such approaches when designing the content of the ‘Superbugs’ shop. We did not shy away from showing the symptoms and wider burdens of particular examples of infections, and the broader implications of AMR in the failure to treat these, which highlighted the current impact of drug-resistant infections, rather than projections or apocalyptic frames. However, alongside this was a message of positivity, detailing the many strategies by which we are fighting the issue of AMR, illustrated using multiple examples relevant to the audiences we were engaging. These included improvements to sanitation, agricultural use, surveillance, and the development of new drugs and vaccines, demonstrating how drug-resistant infections are a cross-cutting threat across all of medicine (beyond specific disease areas), which undermine treatments on which we have come to rely. Further to this, we provided many sources of information about how stakeholders can play an important role in the fight, framing the issue as solvable, and providing specific calls to action, for example, that it is important to complete a full course of antibiotics when they are prescribed. In order to be as inclusive as possible, and in line both with the recommendations of the Welsh Government and the specifications of the original grant remit, all activities and information sheets were available bilingually in English and Welsh.

It was decided very early in the project to avoid making any assumptions about prior knowledge of the topic of AMR among the stakeholders, so as not to compromise our overall message. As such, it was decided to begin the narrative of the event on the basics of microbiology, the bacteria that live in, on and around us, before introducing the ideas of infection and treatment. At the forefront of our messaging was an emphasis on AMR as a universal issue, and that anyone could be affected. The project included an explanation of the part that human activity is playing in accelerating the issue. In this way, we hoped to engage the public in AMR from an informed position on their part. Two early career researchers working in the area of AMR were recruited to work alongside the core team’s scientists to form a ‘scientific content’ team, to develop the narrative and details of the exhibition. A description of the stations available to the stakeholders can be seen in Figure 3. Title cards on the wall and hanging from the ceiling, alongside bacterial ‘footprints’, indicated the suggested route around the shop, but visitors were welcome to engage on their own terms.

An outline of the stations of ‘Superbugs: A Pop-up Science Shop’ (Source: Authors, 2022)

Evaluation strategy

It is widely acknowledged that rigorous and impactful evaluation of public engagement events is challenging, particularly in multifaceted projects such as ‘Superbugs’. We wished not only to evaluate our ability to improve the awareness of AMR in our visitors, but also to evaluate the forum of a pop-up science shop itself as an effective public engagement delivery strategy. To achieve this, we took a multidimensional approach to evaluation, collecting data in a variety of ways to provide as detailed a data set as possible, with reference to a common evaluation framework proposed by Reed et al. (2018) (see Table 2). This framework provided a philosophical backdrop for our evaluation strategy, and we will adopt several of the principles outlined within it in future iterations of our ‘Superbugs’ events. As part of our evaluation strategy, the team reviewed the possible outcomes and impacts of the novel project approach through development of a logic model (Table 1), which explored the inputs, outputs, activities, outcomes and impacts of the project. This was adapted on numerous occasions to ensure feasibility and reach.

External outputs

The event received a notable amount of local media attention. We were involved in a fun feature on the Josh & Kally radio show for Capital FM South Wales. The presenters were invited to swab themselves live on air, and we returned the next day to deliver the results as to who grew the most microbes. This was a unique way to engage a young demographic with the topic of bacteria, and to inform wider groups about the ongoing ‘Superbugs’ event. The local television station Cardiff TV spent over an hour in the shop filming visitors engaging with our activities, and interviewing members of the ‘Superbugs’ team. Two videos were produced and shown repeatedly across the local area for the remainder of the event, and they can be found on the events homepage (https://www.cardiff.ac.uk/superbugs).

We were also able to raise interest and attention from high-profile stakeholders, including Kirsty Williams AM (Welsh Minister for Education and Skills), and a visit from the local Member of Parliament for Cardiff Central, Jo Stevens (then Shadow Secretary of State for Digital, Culture, Media and Sport), in addition to tweets and retweets by several Welsh journalists. Jo Stevens took part in various ‘Superbugs’ activities, including swabbing her mobile phone to grow any contaminating microbes, and she wrote a blog post about her experience.

More recently, ‘Superbugs’ was accepted as an entry to the National Co-ordinating Centre for Public Engagement (NCCPE) ‘Engage 2020’ conference that took place online between 30 November and 4 December 2020. Our video submission to the event can be found on YouTube as part of NCCPE’s ‘Examples of practice’ playlist (NCCPE, 2020).

Impact on public engagement delivery strategy

A primary aim of ‘Superbugs’ was to evaluate this form of public engagement, a novel proposal both for the School of Medicine, and for Cardiff University as a whole. We hypothesised that this mode of delivery would be successful in reaching a wide demographic, beyond the limited cohorts who would typically seek out opportunities to engage in scientific research. We were able to collect school locations for many of our newly crowned Antibiotic Resistance Champions (Figure 5), accounting for 1,626 children across at least two hundred schools. We cross-referenced this data with the WIMD interactive tool (Welsh Government, 2019), the ‘official measure of relative deprivation for small areas in Wales’. The WIMD considers eight distinct domains: income, employment, health, education, access to services, community safety, physical environment and housing. Rather than focus on one domain in particular, we considered ‘overall deprivation’ in our analysis. Of the schools referenced in Figure 5, 43 schools were found to be within the 30 per cent most deprived areas in Wales, and 16 of these were found to be located within the 10 per cent most deprived areas in Wales.

Questionnaire data showed that 67.3 per cent of entries were impromptu visits with no prior knowledge of the event before spotting it on the concourse of St David’s (Figure 6). This was significantly higher than those visitors indicating any awareness due to aspects of our promotional campaign, including advertisements in the Primary Times magazine, website and social media. While confirming our hypothesis, it was also a triumph for the imaginative and imposing exterior designed by our team and informed by our focus group. This also suggests that for future engagement events located in public spaces, significant resources may be better focused on providing the most attractive possible experience for visitors, alongside a less broad, more targeted promotional campaign in keeping with what was delivered for ‘Superbugs’.

Figure 6:

‘Where did you hear about “Superbugs: A Pop-up Science Shop”?’ (Questionnaire Q9): (A) Social media (Facebook, Twitter), including Primary Times; (B) Cardiff University website; (C) Newsletter from local school; (D) Spotted the shop while visiting St David’s; (E) Other; data collected from questionnaires over 14 consecutive days (n=656); individual data points show daily answers; error bars show mean values and 95 per cent confidence intervals (Source: Authors, 2022)

The importance of our focus group in shaping the nature of the content and the overall design theme for ‘Superbugs’, and the impact this had on the success of the event, illustrates the potential in utilising focus groups, public involvement and co-production in shaping such projects. We hope this leads to developing a culture of increased efforts for co-production and public involvement across engagement activities, to the benefit of the scientific community and public alike.

Further confidence in our strategy was corroborated in the data collected through our questionnaires (Table 3): 95 per cent and 91.9 per cent of visitors, respectively, agreed/strongly agreed that the event was fun, engaging and informative, and that we had pitched the intellectual level appropriately. We are very proud to say that over 94 per cent of visitors indicated that they not only rated ‘Superbugs’ as very good or excellent, but, perhaps even more significantly, they would also recommend ‘Superbugs’ to others.

Following a visit, Professor Kim Graham, Pro-Vice Chancellor for Research, Innovation and Enterprise at Cardiff University, and Professor Gary Baxter, Pro-Vice Chancellor for the College of Biomedical and Life Sciences at Cardiff University, took to social media with positive tweets of their experience, and encouraged others to visit ‘Superbugs’. This endorsement from senior leaders at the university highlighted the high-level profile of the ‘Superbugs’ project, and the significance of public engagement with research for higher education institutions. Future conversations were invited from senior leaders to explore this model of engagement, its potential for societal change and how such activities can be sustained in the longer term.

Impact on AMR awareness for stakeholders

We may accept the hypothesis that our pop-up shop was an effective way of imparting positive impact on AMR awareness to the public audience with whom we engaged. Our benchmarking exercise, where visitors were asked to indicate their understanding of three simple but targeted questions to gauge their baseline knowledge, before repeating the exercise on leaving, provides strong supportive evidence for this. The three questions asked are shown in Figure 7. Across all three questions, there was a significant increase in the percentage of correct answers after engaging with the ‘Superbugs’ activities. The largest increase was seen in the most fundamental question, ‘Antibiotics are used to kill …’. The rate of visitors correctly answering ‘bacteria’ increased from 53.1 per cent to 80.7 per cent. This illustrates not only the positive impact we had on our stakeholders, but also the pertinence of engagement on such fundamental topics.

Figure 7:

Comparison of correct answers to benchmarking questions by stakeholders on entry and exit to ‘Superbugs’ (questions are listed with correct answers underlined) (Source: Authors, 2022)

[Q1] ‘Antibiotics are used to kill…’ (A) Viruses, (B) Bacteria, (C) Fungi, (D) All of the above.

[Q2] ‘When taking antibiotics you should…’ (A) stop when you feel better, (B) Take all the antibiotics as instructed by your doctor, (C) Save some for next time you feel unwell, (D) Share them with your friends.

[Q3] ‘Antibiotic resistance is a problem for…’ (A) only people taking antibiotics, (B) Everyone, (C) The elderly and sick, (D) Those who travel to exotic countries.

Table 3 further illustrates that ‘Superbugs’ improved understanding of the world of microbes, antibiotics (and how they work) and antibiotic resistance in 92.7 per cent, 92.5 per cent and 91.7 per cent of cases, respectively. Perhaps more significantly, our evidence supports a progressive influence on future behaviour and attitudes towards antibiotic stewardship, with 90.8 per cent of participants now more likely to complete a full course of antibiotics. Improved antibiotic stewardship has significant and far-reaching implications for our ability to control AMR pathogens (File et al., 2014).

Secondary to this, we may infer far-reaching legacy impact of our event: 1,626 young people left not only with the title ‘Antibiotic Resistance Champion’, but also with their certificate detailing tips about how they can further their knowledge and spread the word long after the doors of ‘Superbugs’ had closed. As a testimony to the success of this approach, 91.3 per cent of visitors completing the questionnaire stated that they would pass on what they had learnt at the event (Table 3).

Impact for the institute and staff

‘Superbugs’ provided a valuable opportunity for professional development for all involved. For several of the core team, it was their first experience of independently securing grant funding, and the organisational and administrative responsibilities that come with it.

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

As described, we saw an incredible response to our Station 4 ‘Grow your own microbes’ activity, with 2,169 swab plates collected. The enthusiasm with which visitors engaged with this suggests a potentially rich resource that could be employed for research purposes, and could provide a unique insight into the social and environmental spread of target microorganisms, and the anthropogenic factors driving this dissemination.

‘Superbugs’ instigated a significant influx of activity and attention to the social media and web pages of the School of Medicine public engagement team. Across the academic year, the School of Medicine delivers a wide portfolio of engagement activities for students at primary and secondary schools, and the wider public, including a free-access public lecture series, the Wales-wide Life Sciences Challenge quiz, and the ‘Science in Health Live!’ event and laboratory work experience scheme that both provide unique opportunities for Year 12 school students to visit the working environment of the University Hospital of Wales in Cardiff (https://www.cardiff.ac.uk/medicine/about-us/engagement), witnessing cutting-edge technologies and research at first hand.

Access for protected characteristics

A cornerstone of the delivery strategy of ‘Superbugs’ was the hope to break out from traditional cohorts of those scientifically aware, to wider and more diverse demographics, including those of age, culture and religion. Enrolling Diverse Cymru as a strategic partner provided us with an independent and judicious evaluation of how ‘Superbugs’ met the needs of, and appealed to, people with protected characteristics, and ways in which we could improve this even further for future activities. This was considered during the design of the shop layout, ensuring information and activities were accessible for a range of heights and abilities, and that there was adequate space to accommodate mobility aids. Highlighted was the need to more apparently cater for those with sensory, learning and cognitive impairments, primarily in some of the language used in areas of the shop, and the prominence of instructions for our activities. In addition, we are committed to applying decolonisation of all information provided in future ‘Superbugs’ events, to reflect a more accurate, diverse and global view of the topic area.

Limitations and future improvements

‘Superbugs’ was delivered in one city-centre location in Cardiff, the capital of Wales. It is the ambition of the project team that future deliveries of ‘Superbugs’ events act to widen the accessibility to include other cities and towns across Wales, particularly those outside southern hubs. This would enable us to compare the impact of ‘Superbugs’ across different geographical and socio-economic areas, of more diverse stakeholder demographics, and provide deeper data sets with which to evaluate the efficacy of our engagement model. Immediate barriers to this exist, however, primarily in the acquisition of unique funding sources, and the recruitment of adequate volunteer numbers.

As has already been indicated, this project was built upon the time and hard work of the core project team, and the willingness of an army of volunteers to give up their own time to participate. In the lead-up to the event itself, we began a recruitment drive through the communication networks of the School of Medicine, and, more widely, the College of Biomedical Life Sciences. Regrettably, uptake outside the research groups of the involved academics was limited, and at certain times volunteer numbers during the event were limited to the point of threatening to compromise the experience for our visitors. Notwithstanding this, ‘Superbugs’ presented a valuable, but missed, opportunity to develop communication and outreach skills, and to gain insight into how public engagement activity with research may support the development of pathway to impact statements. It should be noted that one potential contributor to this was the timing of the event during the summer holidays, perhaps suggesting the importance of budgeting of staff time in the organisation of large-scale engagement and outreach events.

This also highlights an intrinsic issue within academic culture and attitudes towards public engagement activities. Historically, public engagement may have been seen simply as a way in which to educate the ‘scientifically illiterate’. As such, the discipline of public engagement has been underserved in time, attention, funding and willingness to participate (as evidenced here) by academic institutions and the staff therein, perhaps being seen as nothing more than a pleasant aside to the primary roles of researchers. This is exacerbated by an environment that prioritises quantifiable publications and grant funding in determining career prospects and progression.

The introduction of ‘impact’ (encompassing public engagement) as an element of assessment for REF 2014 is perhaps a clear signal of a slow paradigm shift in this regard, and the value with which public engagement and impact is perceived (Copley, 2018). Increasingly, public engagement is seen as a tool to raise university profiles, influence policymakers (both directly and indirectly) and further quantify research impact. In this context, we are proud that our efforts have been recognised with the Cardiff University School of Medicine’s STAR Award 2020 for ‘Outstanding Contribution to Engagement Activities’, awarded to the team lead, Dr Jonathan Tyrrell, in June 2021. More standardised frameworks for the design, implementation and evaluation of public engagement activities are required to advance the integrity and rigour of this capacious discipline, and there is a growing literature to achieve this (Mahony and Stephansen, 2017). Furthermore, as the demand for public engagement with research activities continues to increase from funders, concern around recognition, value and support among employers requires further exploration.

Consent for publication statement

The authors declare that participants’ informed consent to publication of findings – including photos, videos and any personal or identifiable information – was secured prior to publication.