GADSA: Persuasive Gamified Antimicrobial Stewardship Decision Support App for Antibiotics Prescribing Behaviour Change in Nigeria

Antimicrobial Resistance (AMR) is a prominent global threat. The spread of AMR is further accelerated by the inappropriate use of antibiotics. While misuse and overuse of antibiotics are particular global challenges regardless of resources and settings, there is evidence these are amplified in low-to-middle income countries (LMIC) such as Nigeria. While successful antimicrobial stewardship (AMS) programmes have been implemented in LMIC, more research is required to better understand how to overcome some of the underlying reasons and behaviour obstacles, such as lack of training, limited resources, culture and inadequate infection prevention and control practice. This is of particular importance for prophylactic antibiotic prescribing to prevent surgical site infections (SSI). Evidence-based guidelines published by the World Health Organization (WHO) and other public health agencies advise on best practice for prescribing and administering prophylactic surgical antibiotics. However, compliance with such guidelines amongst surgical teams is often limited. The development of engaging decision support tools, accessible at the point of care, at low cost for use in LMICs, is required to help surgeons apply AMS guidelines to their daily practice. Serious mobile games, developed with an educational or training purpose rather than for entertainment, are a powerful tool for persuasive behaviour change but little interest has been given to research for AMR to change prescription behaviour in LMIC. In this research we present the co-development of a decision support tool for the 'Gamified Antimicrobial Stewardship Decision Support App' (GADSA) in Nigeria with surgeons from three participating hospital sites. GADSA is the first gamified decision support app using persuasive games techniques for prescribing behaviour change demonstrated to deliver a prescription behaviour change increasing compliance with SSI guidelines at the point of care. GADSA is also is novel at providing decision support for surgical antibiotic prescribing through gamified features such instruction of mentor, visual and textual immediate feedback system, persuasive messaging and positive and negative reinforcement.