Article Text

Original research
Optimising antimicrobial stewardship interventions in English primary care: a behavioural analysis of qualitative and intervention studies
  1. Aleksandra J. Borek1,
  2. Marta Wanat1,
  3. Louise Atkins2,
  4. Anna Sallis3,
  5. Diane Ashiru-Oredope4,
  6. Elizabeth Beech5,
  7. Christopher C. Butler1,
  8. Tim Chadborn3,
  9. Susan Hopkins4,
  10. Leah Jones6,
  11. Cliodna A. M. McNulty6,
  12. Nia Roberts7,
  13. Karen Shaw4,8,
  14. Esther Taborn5,9,
  15. Sarah Tonkin-Crine1
  1. 1Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
  2. 2Centre for Behaviour Change, University College London, London, UK
  3. 3Behavioural Insights, Public Health England, London, UK
  4. 4Antimicrobial Resistance and Stewardship and Healthcare Associated Infections (HCAI), Public Health England, London, UK
  5. 5NHS England and NHS Improvement, London, UK
  6. 6Primary Care and Interventions Unit, Public Health England, Gloucester, UK
  7. 7Bodleian Health Care Libraries, University of Oxford, Oxford, UK
  8. 8University College London Hospitals NHS Foundation Trust, London, UK
  9. 9NHS East Kent Clinical Commissioning Groups, Canterbury, UK
  1. Correspondence to Dr Aleksandra J. Borek; aleksandra.borek{at}


Objective While various interventions have helped reduce antibiotic prescribing, further gains can be made. This study aimed to identify ways to optimise antimicrobial stewardship (AMS) interventions by assessing the extent to which important influences on antibiotic prescribing are addressed (or not) by behavioural content of AMS interventions.

Settings English primary care.

Interventions AMS interventions targeting healthcare professionals’ antibiotic prescribing for respiratory tract infections.

Methods We conducted two rapid reviews. The first included qualitative studies with healthcare professionals on self-reported influences on antibiotic prescribing. The influences were inductively coded and categorised using the Theoretical Domains Framework (TDF). Prespecified criteria were used to identify key TDF domains. The second review included studies of AMS interventions. Data on effectiveness were extracted. Components of effective interventions were extracted and coded using the TDF, Behaviour Change Wheel and Behaviour Change Techniques (BCTs) taxonomy. Using prespecified matrices, we assessed the extent to which BCTs and intervention functions addressed the key TDF domains of influences on prescribing.

Results We identified 13 qualitative studies, 41 types of influences on antibiotic prescribing and 6 key TDF domains of influences: ‘beliefs about consequences’, ‘social influences’, ‘skills’, ‘environmental context and resources’, ‘intentions’ and ‘emotions’. We identified 17 research-tested AMS interventions; nine of them effective and four nationally implemented. Interventions addressed all six key TDF domains of influences. Four of these six key TDF domains were addressed by 50%–67% BCTs that were theoretically congruent with these domains, whereas TDF domain 'skills' was addressed by 24% of congruent BCTs and 'emotions' by none.

Conclusions Further improvement of antibiotic prescribing could be facilitated by: (1) national implementation of effective research-tested AMS interventions (eg, electronic decision support tools, training in interactive use of leaflets, point-of-care testing); (2) targeting important, less-addressed TDF domains (eg, 'skills', 'emotions'); (3) using relevant, under-used BCTs to target key TDF domains (eg, ‘forming/reversing habits’, ‘reducing negative emotions’, ‘social support’). These could be incorporated into existing, or developed as new, AMS interventions.

  • public health
  • primary care
  • respiratory infections
  • public health
  • qualitative research

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  • Twitter @BorekAleksandra, @marta_wanat, @ChrisColButler, @SKGTonkinCrine

  • Contributors Study conception: AS, TC, ST-C; study design: ST-C, AJB, MW, AS; advising on design and methodology: LA, DA-O, EB, CCB, TC, SH, LJ, CAMM, NR, KS, ET; data acquisition: AJB, NR, LA, AS; data analysis: AJB, MW, ST-C, AS, LA; interpretation: AJB, MW, ST-C, LA, AS, DA-O, EB, CCB, TC, SH, LJ, CAMM, KS, ET; manuscript drafting: AJB; manuscript revisions and approval for submission: all authors.

  • Funding This study was commissioned and funded by Public Health England Behavioural Insights, and was carried out as a collaboration between the University of Oxford and Public Health England, with support from the Centre for Behaviour Change, University College London. STC was supported by funding from the National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance at University of Oxford in partnership with Public Health England (HPRU-2012-10041).

  • Disclaimer The views and opinions expressed in this paper are those of the authors and not necessarily those of the NHS, NIHR, the Department of Health and Social Care or Public Health England.

  • Competing interests Several authors have been involved in developing and evaluating the interventions assessed. CAMM and LJ are involved in ongoing maintenance and promotion of the TARGET toolkit. CCB and ST-C were involved in evaluating communication skills training and point-of-care CRP testing. TC and AS were involved in designing and evaluating the impact of the Chief Medical Officer letters to high prescribing practices.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data relevant to the study are included as supplementary documents and are available from the corresponding author upon reasonable request.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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