Since there was a dearth of literature on utilization of CPG on antimicrobial’ utilization and its potential determinants, this study described the current status of regarding CPG utilization and comprehensively identified its potential influencing factors from the domains of physician belief, CPG traits and hospital practice. The results of this study will not only provide direct guidance on implementation of CPG on antimicrobial, but also add the research knowledge and evidence on CPG use, and further provide beneficial reference for expanding CPG impact.
As demonstrated in this study, about eighty percent of the surveyed physicians reported their strict adherence to the CPG on antimicrobial and active participant in regarding training, and more than seventy percent of the participants have recommended the CPG on antimicrobial to their colleagues. These result indicated fairly high utilization level of CPG on antimicrobial. Many physicians had implemented the CPG in their work and actively took their efforts to expand the CPG use.
With respect to the determinants identification, dimensions of “subjective norm”, “perceived risk” and “behavioral intention” from the domain of physician belief, dimension of “ease of use” from the domain of CPG traits, and dimensions of “top management support” and “organization & implementation” from the domain of hospital practice showed significant association with physicians’ CPG use. And physicians who worked in different department have significant effects on their utilization of CPG on antimicrobial, while other demographic characteristics of physician were not found to be significantly related to the CPG use. Besides, for the potential influencing factors of the hospital characteristics, region is a significant factor affecting physicians’ CPG use as physicians in the eastern region had a lower utilization of CPG on antimicrobial. However, association between hospital rank and the CPG use was not found.
In consistence with many previous studies, this result also highlights the importance of organizational implementation and management support [17,27,28]. With regard to promoting the use of CPG on antimicrobials, the “organization & implementation” activities (routine information collection, inspection, supervision, evaluation, feedback, etc.) will greatly benefit shaping expected behavior and norms of the medical staff. And the concrete support (information, education, funds, personnel, etc.) from hospital administrators also expects to play a positive role in leading a smooth process of CPG uptake. Besides, having been deemed as powerful predictors in former studies, many factors on physician belief also demonstrated their significant effect on the use of CPG on antimicrobial in this research. Such as subjective norm, a kind of perceived norm and pressure from influential persons, it is unsurprisingly for its significant association with CPG use detected in this study. Especially in the setting of public hospitals with a clear hierarchical system , it seems inevitable for the individual to subject to invisible pressure from all around like colleagues or superiors, and comply with perceived norms and orders , such as strictly adherence to the CPG or greatly emphasis on physician autonomy. This point is also mutually verified with the previous content that significant impact of organizational activities on CPG use. Additionally to the hospital practice and physician belief, the impact of CPG traits on CPG use also can’t be ignored. This study also reveals that physicians tend to adopt the CPG easy to master and use. To avoid taking the first-line physicians too much time and effort to learn CPG and put it into practice, it will be wise to concise the CPG on antimicrobials as much as possible. And some brief explanations to the key points will be probably appreciated and further benefit the expanding use of CPG.
However, in contrary with previous researches [20,31], significant effects of attitude and relative advantage were not detected in this study. The plausible reason may be that many physicians are required to follow CPG on antimicrobial by their organization whatever their subjective attitude or assessment towards certain guideline . Anyone who disobeys CPG will confront with great pressure from their organization . This finding also further confirmed the impact of subjective norm and perceived risk. Additionally, there are also other contraries to former papers that younger physicians or with fewer years’ experience tended to be more likely to use guidelines [32,33]. Such difference may be resorted to the situation that physicians in East Asia be easily “institutionalized” when they first enrolled in the working hospital. These results also imply the great importance of organizational impact, which also explained the phenomena reported in the current studies that physicians working in different departments demonstrated great differences in compliance with CPG .
Generally speaking, the results of this study will not only guide the real practice of promoting the use of CPG on antimicrobials, but also intend to provide clues or inspirations for future research. In additional to its significance, this study is also strengthened by some features. On the one hand, with representation from 16 hospitals in eastern, central and western parts of the nation, the important facilitators and barriers to utilization of CPG on antimicrobial determined in this study will be generalizable to the setting of health care system in China. As the largest developing country with the largest population, China’s experience in promoting the use of CPG on antimicrobials will provide helpful reference for other countries, especially the most developing countries in the world. On the other hand, considering cluster bias, multilevel analysis model is applied in the data analysis, which will be more robust in investigating the potential influencing factors from different levels. However, there are still some limitations of this study. First of all, owing to the social desirability bias , the participants of this study may be unwilling to voice negative assessment about themselves and the hospitals, which may directly lead to overestimation of the attitude, belief, intention and utilization of CPG on antimicrobial. Secondly, clustering effects were found at the organizational (hospital) level, while the number of selected tertiary and secondary hospitals was not balanced well. Although rankings of the hospitals did not show its significance, it still cannot eliminate the effects caused by the rankings. Thirdly, this study is also limited by collecting cross-sectional data at a single point-in-time to determine the influencing factors, it may be more prudent to investigate the causality by panel session data or so on in future research.