In this section we describe the findings of (1) the qualitative research study and (2) the multi-disciplinary knowledge co-production workshop .
The factors identified during the interviews that influence the prescription of surgical prophylaxis were linked to eight out of fourteen domains of the TDF framework, including knowledge, beliefs in consequences, communication skills, professional role, psychological reactions, environmental context, optimism, and reinforcement.
Respondents discussed how their limited knowledge influenced the prescription of antibiotics for surgical prophylaxis. Most respondents discussed having learned how to prescribe antibiotics for surgical prophylaxis from senior physicians during their residency, “This is what I learned during my residency by observing others and my superiors. This is what we all do”- Orthopaedic surgeon, resident.
Several respondents highlighted that they did not know enough about appropriate antibiotic prescribing. Likewise, several respondents mentioned that they were not clear about how to prescribe antibiotics appropriately, “I was not trained to prescribe antibiotics. I do what I have to do, but it is not based on any knowledge. I would need to Google if I want to prescribe correctly. I don’t have time for it.” - Orthopaedic surgeon, consultant.
Domain: Belief in consequences of prescribing antibiotics without following guidelines
Respondents discussed AMR as a consequence of improper prescription of antibiotics for surgical prophylaxis. All respondents were aware of antibiotic resistance as a global phenomenon. Many of them were also convinced that AMR was more common in Egypt. However, respondents had given little thought to their own antibiotic prescription practices as a contributing factor to AMR. Instead they blamed community pharmacists and patients for the overuse. For example, one Orthopaedic surgeon, consultant said “All I can say is that this is a big problem in Egypt. People and pharmacists use antibiotics without any control whatsoever.”
Domain: Belief in the consequences of prescribing antibiotics by following international guidelines
Many respondents were aware about the international guidelines for antibiotic prescription ; however, they did not believe that these guidelines were applicable in the Egyptian context because they believed that international guidelines were developed in the context of western countries where AMR was less of a problem than in Egypt.
“In Egypt AMR is a big problem. For that reason we have to prescribe more stronger antibiotics and for longer periods of time than elsewhere.” (Orthopaedic consultant)
Domain: Communication skills
Respondents discussed the critical role communication skills could play when answering patient demand for receiving antibiotics following hospital discharge. They acknowledged that the practice was unnecessary nor supported by any evidence, but also thought that halting the prescription of antibiotics after hospital discharge would not be readily accepted by patients. An orthopaedic surgeon consultant said “Patients tell me what they want. Yes, I discuss with them, but they don’t always listen to me. They may not consider my advice about antibiotics.”
Domain: Professional role
Junior doctors highlighted that senior physicians were always the decision makers if they were involved in the prescription for surgical prophylaxis, as indicated by a resident orthopaedic surgeon. “We follow what senior doctors are recommending.” It was also highlighted that clinical pharmacists had no role to play in the prescription of antibiotics unless there was a patient with resistant infections. “We do not benefit from the pharmacological knowledge of clinical pharmacists. We don’t have them.”- Orthopaedic surgeon, consultant.
However, many residents cited that communication between senior and junior doctors was often limited and, as such, they were left with limited guidance on how to prescribe antibiotics. “Sometimes we don’t see our consultant at all. He may not follow the case much. I can go back to him if I have a problem” - Orthopaedic surgeon, resident. Respondents also highlighted that different orthopaedic surgery specialties had different undocumented group rules for surgical prophylaxis, however, there is no group pressure to follow them. “There is nobody checking if we follow the rules or not, but most do what we all do” - Orthopaedic surgeon, resident. The undocumented rules mentioned included the type of antibiotic and the duration of the antibiotic course.
Domain: Psychological reactions
Respondents discussed the fear of patient acquisition of infection due to ineffective IPC programmes as a factor that influenced their prescription of antibiotics for surgical prophylaxis. This fear of infections encouraged prescribers to prolong the duration of antibiotics and to use broad spectrum antibiotics which are not recommended by international guidelines. The limited confidence in the effectiveness of the hospital’s IPC programme contributed to the practice of antibiotic prescribing. “Here in the hospital there are no IPC measures implemented. Doctors and nurses practice as they wish. There is no follow up. Where is the IPC team?”-Orthopaedic surgeon, consultant. Some of the respondents referred to breaches of IPC practices they witnessed, such as entering the operating theatre multiple times with the same personal protective equipment, not using masks or gloves as per guidelines, insufficient sterilization of surgical equipment, breaches in environmental cleaning, as well as overall crowdness in the wards, construction work, and a lack of nursing staff.
The patients were another source of fear of infection as most are from low socio-economic backgrounds and respondents believe they tend to be prone to infection due to poor general health conditions, nutritional status, and unhygienic living conditions. One resident orthopaedic surgeon explained, “Our patients are so fragile. It is easy for them to acquire an infection. That’s why we cannot comply with any international guidelines. We are different.”
Many respondents noted that inadequate hospital infrastructure might be a contributing factor to the acquisition of hospital-acquired infections. Examples are: overcrowded wards with lots of visitors who stayed for extended periods of time at bedsides, continuous construction work, and limited air conditioning in different areas of the hospital. Another orthopaedic surgeon, resident noted, “In a private hospital we have one patient per room, and we have nice furniture and surroundings. But here in the government hospital we have to use antibiotics to kill any germs in the environment.”
Domain: Environmental context
Respondents also explained that their selection of certain types of antibiotics is influenced by availability within the hospital. On many occasions, certain types of antibiotics are out of stock and sometimes broad-spectrum antibiotics are also unavailable.
Respondents explained that they did not have guidelines for surgical prophylaxis based on their Egyptian context, “We don’t follow any guidelines as we don’t have guidelines”- Orthopaedic surgeon, consultant.
Domain: Optimism
Responses regarding the belief in changes to prescribing practices varied significantly, but most respondents did not believe that change in prescribing behaviour can happen, “This is our practice. Changes are not possible.”- Orthopaedic surgeon, consultant. Many explained that senior staff and eminent surgeons in particular will not change their current prescribing practices. Some believed that over time change could be introduced but that would require everyone in the department to follow a specific policy. Others cited that changes could be introduced when IPC practices were improved, “Sure, sometime later when our hospital is in better shape and infection control practices are well institutionalized”- Orthopaedic surgeon, consultant.
Domain: Reinforcement
All respondents agreed that there was no follow up or feedback on their antibiotic prescribing practices including surgical prophylaxis. There is no follow up or peer control, “Nobody follows how we prescribe antibiotics. There is no positive or negative feedback”- Orthopaedic surgeon, consultant.
Workshop of knowledge co-production
The workshop resulted in the selection of five behavioural domains to be addressed in the behaviour change intervention based on the qualitative research study, followed by selecting five intervention functions which correspond with the BCW framework and are in line with global best practices. Workshop participants selected the interventions which were evaluated based on their acceptability, practicality and how well they can be implemented on a large-scale basis. The intervention functions and activities can be found in Table 2.
Table 2
Suggested behaviour change functions and activities
Behavioural Domain
|
BCW intervention function
|
Activities
|
Knowledge
|
Education
|
• Educational sessions
• Advocacy meetings
|
Beliefs in capabilities
|
Enablement
|
Infection Prevention and Control improvements and training
|
Professional role
|
Persuasion
|
• Advocacy to engage senior physicians
• Promotion of positive self-images of physicians
|
Environmental factors
|
Environmental restructuring
|
Guidelines for surgical prophylaxis
|
Reinforcement
|
Restriction
|
Feedback system with restrictions
|
Domain: Knowledge
The qualitative research study indicated that there is lack of knowledge about antibiotic prescription among orthopaedic surgeons, thus highlighting the relevant TDF theme of ‘knowledge’. The BCW intervention which corresponds with ‘knowledge’ is ‘education’. The rapid literature review indicated that educational interventions alone have little impact on behaviour change [33–35].However, many interventions that use several elements including an educational component provided evidence that education together with other interventions can have a positive impact on behaviour change [ 36–40].
The workshop participants discussed how educational sessions in general are perceived as culturally acceptable interventions, but also how inviting senior staff to an education session is believed to be a sensitive issue because it could be interpreted by senior staff as undermining their knowledge and skills. This was not believed to be a problem among junior staff who may find educational opportunities appealing. The workshop participants highlighted that the composition of educational session participants must be planned carefully and introduced in a way that follows the hierarchies of Egyptian hospitals.
From a practical point of view, organizing educational sessions was considered difficult because doctors were generally busy. Incorporating educational components into existing hospital staff meetings and continuous educational trainings was therefore considered more feasible. Workshop participants agreed that educational sessions are easily approved by the hospital management. Therefore, such sessions were considered easily implementable even on a larger scale within the hospital. Workshop participants also agreed that the behaviour change intervention should include educational sessions for residents. In addition, educational messages in the form of advocacy for AMR could be incorporated into regular unit meetings where senior staff meet.
Domain: Beliefs in capabilities
The qualitative research study pointed out that one of the major drivers of current misuse of antibiotics was a fear of the acquisition of hospital acquired infections, linked to beliefs about insufficient infection control measures as well as the poor general health and unhygienic living environments of patients.
Literature shows that multi-faceted antibiotic stewardship programs including structural adjustments to improve IPC measures showed positive results in changing prescription practices [41–43].
The BCW intervention concerning reducing the fear of patient acquisition of hospital acquired infections through improvements in IPC corresponds with the TDF theme of ‘enablement,’ which itself refers to modifications in the enabling environment. Accordingly, respondents discussed the need to improve IPC programmes, which is a concrete, visible and measurable action that is likely to be strongly welcomed by all healthcare workers. Workshop participants also believed that enhancing IPC measures would provide an opportunity for the IPC team to become more visible and appreciated. An IPC related intervention was considered practical as ASUH has a large and well-trained IPC staff that can incorporate additional IPC measures to support the orthopaedic surgeons. However, the intervention is likely to require some advocacy as IPC related measures are not prioritized by the hospital administration.
Domain: Professional role
The qualitative research study illustrated that the role of senior doctors was critical in many ways. Accordingly, the workshop participants highlighted the importance of paying special attention to the senior staff. They agreed that getting senior staff on board would ensure the intervention’s acceptability to all staff working in the hospital, and it’s approval by the hospital administration which tends to align with senior doctors in decision making. Workshop participants also discussed that doctors could be encouraged to change their prescription practices though promotion of positive professional images as Egyptian doctors take great pride in being reputable doctors. The BCW intervention function corresponding with professional role was the TDF theme of ‘persuasion,’ and workshop participants agreed to include persuasion by developing appropriate activities such as reminders that address senior staff to emphasize their role in the intervention.
Domain: Environmental factors
The qualitative study revealed that neither the hospital nor the orthopaedic department had guidelines or policies for antibiotic prescription in general, including surgical prophylaxis. Although the literature on AMR suggests that introducing antibiotic guidelines and policies alone does not always result in behaviour change, when including guidelines as a part of an intervention bundle there seems to have been a positive impact on improving prescription practices [44–49].
The workshop participants indicated that guidelines can be acceptable if the introduction of them takes place gradually, starting from the senior staff first. Ideally, the senior staff should be involved in the development of the guidelines to ensure they are accepted and applied by all. The workshop participants also agreed that training and orientation on the guidelines is important to ensure implementation. The scaling up of guidelines was also seen as feasible even on a national scale. The workshop participants therefore agreed to include the TDF theme of ‘environmental restructuring’ as a BCW intervention function that included developing and disseminating hospital-based guidelines for surgical prophylaxis as a part of the intervention.
Domain: Reinforcement
The qualitative findings showed that, currently, there is no follow up of prescription of surgical prophylaxis or prescription of antibiotics in general. The surgeons did not receive any feedback from their peers or the management regarding their antibiotic prescription practices. Yet, the rapid review pointed out that multi-component interventions that includes follow up, audits, or feedback systems were generally effective in changing prescription [ 36–39, 40,].
The workshop participants discussed how implementing a feedback or audit system would not be easily accepted by the doctors who are used to making decisions about antibiotics independently. They believed that senior staff would be the most difficult, if not impossible, to convince them on the importance of such systems – given their view that senior doctors believe they know what works best based on their vast experience. Therefore, workshop participants suggested that the feedback system include ‘restrictions’ that will require surgeons to comply even if they were not in agreement. Restriction systems as part of antibiotic stewardship programs were also used successfully in other international settings [50–52].
Workshop participants also discussed including a clinical pharmacist in the follow up system as the rapid literature review showed that the involvement of clinical pharmacists is highly beneficial [53–56].
In addition, the workshop participants highlighted the need to include the hospital management in the feedback system to make it practical. The workshop participants also highlighted that as university hospital in general have similar structures and staffing, the same system can be easily adjusted for other settings.