{"paper_id":"2c699ec3-d7fe-4b0e-a18e-ef7460ce6839","body_text":"1\n1 Title: A qualitative study on factors influencing health \n2 workers’ uptake of a pilot surgical antibiotic prophylaxis \n3 stewardship programme in selected Georgian hospitals\n4\n5 Short Title: Factors influencing pilot SAP stewardship \n6 uptake in Georgia\n7\n8 Sideeka Narayan1, Sahil Khan Warsi1*, Iago Kachkachishvili2, Osiko Kontselidze2, Mariam \n9 Jibuti 2, Nino Esebua2, Ana Papiashvili2, Danilo Lo Fo Wong1, Ketevan Kandelaki1*\n10\n11 1 World Health Organization (WHO) Regional Office for Europe, Copenhagen, Denmark\n12 2 Institute of Social Studies and Analysis, Tbilisi, Georgia\n13\n14 * Corresponding authors\n15 E-mail: kandelakik@who.int (KK)\n16 warsis@who.int (SKW)\n17\n18 SN: writing original draft, review and editing, formal analysis\n19 SKW: conceptualization, methodology, writing original draft, review and editing, formal \n20 analysis, resources, supervision\n21 IK: project administration, methodology, data curation, formal analysis, resources\n22 OK: data curation, formal analysis, visualization\n23 MJ: data curation, formal analysis, visualization\n24 NE: data curation, formal analysis, visualization\n25 AP: data curation, formal analysis, visualization\n26 DLFW: project administration, supervision\n27 KK: conceptualization, methodology, writing original draft, review and editing, formal analysis, \n28 resources, supervision\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309557doi: medRxiv preprint \nNOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.\n\n2\n29 Abstract\n30 Antimicrobial misuse in surgical antibiotic prophylaxis (SAP) can include the inappropriate use \n31 of broad-spectrum antibiotics or prolonged dosing. In 2021, a pilot antimicrobial stewardship \n32 programme (ASP) was launched in Georgia, which involved developing and adapting SAP \n33 guidelines, establishing an interprofessional SAP prescribing approach, collecting surgical site \n34 infection (SSI) data via routinely collected data and telephonic patient follow-ups, and providing \n35 surgical unit staff with prescribing feedback and training on antimicrobial resistance (AMR) and \n36 antimicrobial stewardship (AMS). ASP introduction was staggered across ten hospitals over \n37 three years.\n38\n39 This study explored behavioural determinants of surgical teams’ ASP uptake in five hospitals \n40 where the ASP was introduced or about to be introduced. Findings primarily concerned \n41 epidemiologists’ and nurses’ ASP-related behaviour. Those at ASP non-introduced hospitals \n42 were less involved in the SAP prescribing process, had lower AMR awareness, and lacked \n43 professional development opportunities. Those at ASP-introduced hospitals exhibited higher \n44 AMR knowledge and felt ASP participation boosted confidence, facilitated work, and furnished \n45 key professional development.\n46\n47 Results indicate interprofessional collaboration on SAP prescribing supported ASP uptake across \n48 teams, and investment in health worker training and administrative encouragement ensured \n49 effective ASP participation and implementation. Findings highlight the crucial role of \n50 epidemiologists in SAP and illustrate a need for developing Georgian nurses’ AMR \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309557doi: medRxiv preprint \n\n3\n51 competencies as a vehicle to address public AMR knowledge gaps. Longer-term ASP uptake will \n52 need to consider the regulatory context in which hospitals lack access to national-level SSI data \n53 and feedback on SSI reporting but are fined for reporting non-compliance.\n54\n55 Despite resource limitations and a small sample size, the study engaged all pilot ASP health \n56 workers. Respondents’ inexperience of qualitative research participation and ensuant hesitation \n57 limited exploration of motivational factors supporting health workers' ASP uptake, which could \n58 be explored in further research.\n59\n60 Introduction\n61 Antimicrobial resistance (AMR) is a global threat to public health. AMR occurs when \n62 microorganisms, such as bacteria, viruses, parasites and fungi, change so that they are no \n63 longer affected by antimicrobial medicines used to treat them. The development and spread of \n64 AMR is accelerated by the inappropriate use of antimicrobials, resulting in harder-to-treat \n65 infections.(1–3) The misuse of antimicrobials in health-care settings is one of the key modifiable \n66 drivers of the emergence of AMR. This issue deserves particular attention in surgical wards \n67 where antibiotic prophylaxis is routinely administered prior to surgery to help decrease the risk \n68 of postoperative infections. Addressing surgical antibiotic prophylaxis (SAP) requires an \n69 appreciation and understanding of the behavioural and cultural context influencing health-care \n70 professionals’ practices and decisions.\n71\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309557doi: medRxiv preprint \n\n4\n72 Antimicrobial stewardship programmes (ASPs) are one of the most cost-effective interventions \n73 to optimize antimicrobial use, improve patient outcomes, and reduce the development and \n74 spread of AMR.(4,5) It involves a systematic approach to educate and support health-care \n75 professionals to follow evidence-based guidelines for prescribing and administering \n76 antimicrobials. Educating the health workforce is crucial, as they are key in safeguarding \n77 antimicrobial effectiveness. Successful ASPs not only equip practitioners with information, but \n78 do so by attending to the behavioural factors affecting programme uptake.(6,7)\n79\n80 In Georgia, as in other countries, the inappropriate use of antibiotics, including for surgical \n81 prophylaxis, is characterized by a high use of broad-spectrum antibiotics and prolonged \n82 dosing.(8–10) Actions to contain the development and spread of AMR in Georgia have thus far \n83 mainly focused on strengthening AMR surveillance systems and implementing modern methods \n84 for infection prevention and control (IPC). However, limited actions have been implemented to \n85 establish ASPs and understand the factors affecting their uptake among health \n86 professionals.(11,12)\n87\n88 In 2021, as part of Georgia’s 2017–2020 National action plan (NAP) to contain the spread of AMR, \n89 the International Centre for Antimicrobial Resistance Solutions (ICARS) began a three-year ASP \n90 to develop and introduce SAP guidelines in ten hospitals, aiming for 60% hospital guideline \n91 compliance within 12 months from ASP introduction. The ASP involved AMR and antimicrobial \n92 stewardship (AMS) training for surgical unit staff; data collection on surgical site infection (SSI) \n93 rates via post-surgical patient telephone interviews, and on antibiotic prescribing via monthly \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309557doi: medRxiv preprint \n\n5\n94 point prevalence surveys (PPS); and feedback to surgical teams to adjust prescribing practice. \n95 Regarding health worker behaviours, the ASP primarily involved surgeons following new SAP \n96 guidelines, epidemiologists conducting PPS, and nurses conducting post-surgical patient \n97 interviews. The Ministry of Internally Displaced Persons from the Occupied Territories, Labor, \n98 Health and Social Affairs of Georgia (MoIDPLHSA) and ICARS signed a memorandum of \n99 understanding in September 2021, followed by an official project launch where ASP participating \n100 staff at all ten hospitals were informed on ASP objectives and timelines and their specific roles. \n101 ASP introduction was planned to begin in 2022 in overlapping stages for three hospitals in year \n102 1, four in year 2, and three in year 3.\n103\n104 In collaboration with the MoIDPLHSA and National Centre for Disease Control (NCDC), the WHO \n105 Regional Office for Europe (Regional Office) and WHO Country Office in Georgia undertook a \n106 study in 2022 to identify barriers to and enablers for implementing the ICARS ASP during the first \n107 year of its introduction. The study was conducted in parallel to the ICARS ASP and followed the \n108 WHO Regional Office Tailoring Antimicrobial Resistance Programmes (TAP) method to identify \n109 barriers to and drivers of behaviours contributing to ASP uptake. National researchers from the \n110 Institute of Social Studies and Analysis (ISSA) conducted fieldwork across selected participating \n111 hospitals to understand factors affecting health workers’ ASP-related behaviours. \n112  \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309557doi: medRxiv preprint \n\n6\n113 Methods\n114 Study design and setting\n115 Data collection and analysis were conducted using the Capability, opportunity, and motivation \n116 for behaviour change (COM-B) theory, which is part of the Behaviour change wheel (BCW) \n117 framework to understand and evaluate health-related behaviour interventions.(13) The COM-B \n118 theory is built on a review of 19 existing behaviour change frameworks, and holds that public \n119 health behaviour change is influenced by the interlinked factors of individuals’ capability, \n120 opportunity, and motivation to enact specific behaviours. Fig. 1 below illustrates how the COM-\n121 B factors are approached through TAP.(14)\n122\n123 Fig 1. The COM-B model adapted to AMR \n124\n125 The COM-B theory was employed to understand the behaviour of each target group outlined \n126 below in relation to their function under or related to the ICARS ASP. Across the target groups, \n127 the behaviours explored included SAP prescribing and adherence to guidelines, conducting ASP-\n128 related surveillance and feedback, and integrating the ASP in hospital and surgical team practice. \n129 The behaviours explored for each target group are presented in Table 1 in the results section \n130 below.\n131\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309557doi: medRxiv preprint \n\n7\n132 Data was collected in 2022 from five of the ten hospitals. The research sites represented regional \n133 and hospital variation. Three hospitals were selected from Tbilisi and two from the regions, \n134 representing a large private, smaller private, teaching, maternity, and military hospital. \n135\n136 Research participants\n137 The primary target groups were the ICARS ASP team at each hospital: one hospital administrator, \n138 one AMR champion, one epidemiologist, one surgical unit chief nurse and surgeons. In two \n139 hospitals, the hospital administrator or AMR champion was also a surgeon. In such cases, the \n140 individual participated in research in their administrator or AMR champion capacity and \n141 additional questions were also asked relating to their role as a surgeon. Research was also \n142 conducted with secondary target groups affecting the behaviour of primary target group \n143 participants. This included a clinical pharmacist, health professional association representatives, \n144 and pharmaceutical company representatives. Primary target group participants were sampled \n145 to include the entire ASP team at each hospital, and secondary target group participants were \n146 purposively sampled based on their availability and accessibility. Participants were recruited into \n147 the study from 1 May to 1 July 2022. All participants received information on research and were \n148 given the chance to ask questions before providing written and verbal consent to participate. The \n149 study was conducted in accordance with the Helsinki Declaration (1964, revised 2013), and \n150 received ethical approval from the WHO Research Ethics Committee, protocol number \n151 ERC.0003668, and the Institutional Review Board of the National Center for Disease Control and \n152 Public Health of Georgia, IRB number 2021-066.\n153\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309557doi: medRxiv preprint \n\n8\n154 Data collection and analysis \n155 Given that only one participant in each target group was engaged in the ASP at each hospital, \n156 data was almost entirely collected via semi-structured, in-depth interviews (IDIs). Only one focus \n157 group discussion (FGD) was conducted with surgeons from the three Tbilisi hospitals. IDIs and \n158 the FGD were conducted using research guides, with questions developed via a COM-B-inspired \n159 activity organized by the WHO Regional Office with the participation of representatives from \n160 ICARS, NCDC, MoIDPLHSA, and the ASP hospitals. Questions addressed individuals’ knowledge \n161 and perceptions of AMR and SAP, views on the ASP, and factors affecting ASP incorporation into \n162 hospital practice. The guides were initially developed in English and then translated to Georgian.\n163\n164 Prior to data collection, the WHO Regional Office, ICARS and NCDC researchers conducted a \n165 week-long workshop with the national research team. During this workshop, national \n166 researchers were informed about the Georgian context of SAP and SSIs, the health system \n167 context of Georgia, and trained on COM-B theory and its use in research, data collection, and \n168 analysis. National researchers, jointly with WHO Regional Office, ICARS and NCDC \n169 representatives, reviewed each research guide, line-by-line, for linguistic and contextual \n170 appropriateness, and simultaneously adapted Georgian- and English-language versions to ensure \n171 coherence across all guides. The guides were then piloted before research to ensure feasibility. \n172\n173 All discussions were audio-recorded and transcribed in Georgian before analysis. Transcripts \n174 were anonymized using participant IDs, ensuring no identifying details were included. As WHO \n175 Regional Office researchers could not be present during the initial stage of data collection, four \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309557doi: medRxiv preprint \n\n9\n176 initial transcripts were translated in English and shared with them for feedback and for \n177 preliminary analysis training. A coding framework was developed based on sections of the \n178 research guides. National and WHO Regional Office researchers coded two initial transcripts \n179 separately and then compared results to identify differences. Based on these results, feedback \n180 was provided to national researchers and the coding framework was adapted to allow for \n181 emerging themes across transcripts. A second round of analysis was conducted with the \n182 remaining two English transcripts, with almost identical coding by all researchers. After this \n183 exercise, all transcripts were then coded and analysed directly from Georgian by national \n184 researchers.\n185\n186 Coded data, observations, and quotations were organized into a Microsoft Excel spreadsheet for \n187 each target group in Georgian. National researchers developed a thematic report based on \n188 analysed data which was used by WHO Regional Office researchers to conduct a COM-B analysis \n189 of research findings by target group and hospital type.\n190\n191 Results \n192 A total of 26 IDIs and one FGD were conducted with 31 participants from five hospitals. At the \n193 time of data collection, the ASP had been introduced in three of the five hospitals. Findings on \n194 factors affecting ASP uptake show similarities across target groups as well as differences \n195 between ASP-introduced and non-introduced hospitals. Primary COM-B factor findings are \n196 presented below, and an overview of participants by target group, ASP-related behaviours and \n197 research activities are presented in Table 1.\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309557doi: medRxiv preprint \n\n10\n198\n199 Table 1. Participants by target group, ASP-related behaviour, and research activity\nTarget group ASP-related behaviour Research \nactivity\nTotal \nparticipants\nPrimary target group (ASP participants)\nHospital \nadministrator\nLeads adoption and dissemination \nof SAP guidelines and ASP \nintroduction\nIDI 4\nHospital AMR \nchampion\nCoordinates ASP introduction, \ndata collection/analysis and \nfeedback\nIDI 3\nFGD 5Surgeons Receive training and use \ndeveloped SAP guidelines IDI 5\nEpidemiologists Collect and analyse SSI/PPS data \nfor SAP ASP IDI 5\nStudy nurse Collects SSI data from post-\nsurgery patients IDI 5\nSecondary target group (influencers)\nHospital \npharmacists\nInfluence antibiotic availability \nand prescribing process IDI 1\nProfessional \nassociation\nrepresentatives\nInfluence behaviour of primary \ntarget group professionals IDI 2\nPharmaceutical \ncompany \nrepresentatives\nDirectly advertise and provide \nantibiotics to hospitals IDI 1\nTotal 31\n200\n201 Behaviour\n202 ASP-introduced hospital participants reported active involvement in ASP activities, while ASP \n203 non-introduced hospitals’ participants had limited involvement in similar activities. Variation \n204 was primarily observed across hospitals in epidemiologist and nurse involvement in SAP. \n205 Epidemiologists at all hospitals reported conducting surveillance on health-care associated \n206 infections (HAIs), trainings on issues such as hand hygiene and disinfection-sterilization or HAI \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309557doi: medRxiv preprint \n\n11\n207 reporting to NCDC. ASP-introduced hospital epidemiologists supervised medical staff on and \n208 monitored antibiotic prescription for guideline compliance. Conversely, ASP-non-introduced \n209 hospital epidemiologists were not involved in antibiotic selection or the prescribing process but \n210 believed they should be.\n211 \"As for monitoring the use of antibiotics, I do not monitor what antibiotic the doctor \n212 prescribed and how. We talked about this issue with the quality service, that it is better if we \n213 get more actively involved in the issue. We have a plan to take one in ten cases and check if \n214 antibiotics have been prescribed according to the guideline.”\n215 – Epidemiologist, Hospital 1, ASP non-introduced\n216\n217 Nurses in Georgia administer prescribed antibiotics and supervise therapy; they do not have the \n218 right to prescribe. ASP-introduced hospital nurses were more involved in patients’ treatment, \n219 regularly communicating with them and providing information on AMR and the ASP. They \n220 interviewed patients one-week and one-month post-surgery, recording information on \n221 prescription and non-prescription antibiotic use, complaints and complications. ASP non-\n222 introduced hospital nurses were not involved in such activities. \n223  \n224 Significant behavioural differences across hospitals were not observed for other target groups. \n225 Surgeons develop patients’ antibiotic treatment plans in consultation with other specialties, \n226 although one ASP non-introduced hospital administrator indicated some staff might rely on \n227 experience rather than evidence-based guidelines. Administrators, in general, ensure the \n228 quality and safety of patient care and implement treatment guidelines and monitor their \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309557doi: medRxiv preprint \n\n12\n229 compliance. The AMR champion role was created for ASP; the majority of those in this role \n230 were already engaged in some form of administration or treatment strategizing.\n231\n232 Capability\n233 Although all participants were informed via the 2021 ASP launch, most ASP non-introduced \n234 hospital participants were unaware of their hospital’s participation and their roles. Differences \n235 in knowledge, skills and training were specifically observed among nurses and epidemiologists. \n236 Surgeons stated nurses lack required ASP competencies. A professional association \n237 representative reported AMR knowledge gaps among epidemiologists, citing insufficient up-to-\n238 date information and confirmed by ASP non-introduced hospital epidemiologists’ unfamiliarity \n239 with the Access, watch, reserve (AWaRe) classification. ASP non-introduced nurses and \n240 epidemiologists expressed an interest to participate in trainings to strengthen knowledge of \n241 AMR and the ASP.\n242\n243 ASP-introduced hospital epidemiologists and nurses felt confident in their skills and reported \n244 significant improvement as a result of ASP trainings. Nurses expressed increased AMR and SAP \n245 knowledge, which facilitated patient communication, and believed the additional ASP duties \n246 and understanding of AMR were interesting and important for professional development. \n247 Administrators added that extra communication was often required for patients and their \n248 families to encourage appropriate antibiotic use. Epidemiologists demonstrated awareness of \n249 the AWaRe classification and proactive use of guidelines, reporting this as an important tool for \n250 effective monitoring and supportive to their work. \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309557doi: medRxiv preprint \n\n13\n251 “There were several cases when the doctor did not prescribe an antibiotic, but the patient \n252 replied that they still take it on their own. They even had complaints about it. They still think \n253 it is impossible for the treatment to go well without antibiotics.”\n254 - Nurse, Hospital 5, ASP-introduced\n255\n256 A few capability findings related to participants’ perceptions. Regarding SAP guideline \n257 application, some ASP non-introduced hospital administrators and surgeons believed a \n258 consultative approach to patient antibiotic treatment planning was not necessary as national \n259 guidelines outlined available options. Epidemiologists perceived their facility’s SSI incidence was \n260 low at one to two cases per year.\n261 “We don't need to consult with colleagues [such as infectious disease specialists] on which \n262 antibiotic to use or replace. The Ministry has given us [SAP Guidelines] with the names of only \n263 two antibiotics.” \n264 -Surgeon, Hospital 1, ASP non-introduced\n265\n266 Opportunity\n267 ASP-introduced hospital participants reported that the hospital-specific adaptation of national \n268 SAP guidelines and introduction of the digital patient recording system facilitated antibiotic \n269 treatment and planning. Several ASP-introduced hospital participants mentioned an initial \n270 increase in workload following ASP introduction but reported that this was integrated into \n271 routine practice.\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309557doi: medRxiv preprint \n\n14\n272 “…protocols developed will help health-care facilities use antibiotics more rationally. Besides, \n273 we, as doctors, will obtain knowledge and will disseminate it within the facility... Some \n274 surgeons are employed at several [other] hospitals and will disseminate the knowledge there \n275 as well. “ \n276 -AMR champion, Hospital 4, ASP-introduced\n277 While epidemiologists across all hospitals mentioned having continuous medical education \n278 opportunities on various topics, ASP non-introduced hospital epidemiologists and nurses \n279 reported not receiving AMR-specific training. AMR champions at ASP-introduced hospitals \n280 further reported ASP communication was presented to all services, and that SAP conferences \n281 and trainings were open to all staff, broadening staff involvement and exposure to the ASP. One \n282 epidemiologist said ASP scale-up and sustainability would depend on government enforcement \n283 through integration in national health plans. \n284\n285 Opportunity barriers reported by epidemiologists related to reporting on SSIs. They do not have \n286 access to national-level information on SSIs. Additionally, while hospitals do not receive \n287 feedback from NCDC on SSI reporting, they are fined for non-compliance with reporting \n288 regulations. \n289 “In case of HAIs we report what went wrong and why HAI developed. We have no feedback \n290 but, in case of non-compliance with regulations, the clinic might be fined.”\n291 - Epidemiologist, Hospital 5, ASP-introduced\n292\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309557doi: medRxiv preprint \n\n15\n293 Participants cited the lack of public AMR awareness and demand for antibiotics as a social \n294 opportunity barrier. They added that patients could deviate from doctors’ advice by buying \n295 over-the-counter (OTC) antibiotics. Relatedly, an AMR champion emphasized treatment plans \n296 must be effectively communicated to patients to increase treatment compliance and \n297 confidence. ASP-introduced hospital nurses further reported that patients positively responded \n298 to follow-up calls providing information on AMR, with only few becoming suspicious or anxious \n299 about their health.\n300 “[One challenge] is that the patient or their family member demands antibiotics… we \n301 convince them that it’s not needed. We inform them about the possible side-effects of \n302 inappropriate use of antibiotics… The majority of patients are satisfied when you call them \n303 after the surgery to check on them … in rare cases… even though they are informed in \n304 advance to expect two calls, they can become suspicious.”\n305 - Nurse, Hospital 1, ASP-introduced\n306\n307 “If the information is communicated correctly to the patients and the results are also \n308 favourable, the patient will go along with you. I think it is always possible to overcome \n309 stereotypes if you try. “ \n310 - AMR champion, Hospital 4, ASP-introduced\n311\n312 Motivation\n313 Participants across target groups reported initial hesitancy to the ASP, related to workload, \n314 effectiveness, patient acceptance, and other factors. However, they indicated that hospital \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309557doi: medRxiv preprint \n\n16\n315 context influenced the willingness and ability to support and participate in the ASP. ASP-\n316 introduced hospital administrators reported the programme strengthened staff knowledge and \n317 responsibility. Nurses and epidemiologists specifically welcomed such qualification-raising \n318 opportunities and believed they are integral to ASP implementation. Epidemiologists also \n319 believed that administrators play a role in encouraging ASP acceptance and adherence. \n320 “The initial attitude was skeptical. However, it was seen that the [SAP] was successful…This \n321 requirement has been strengthened by the guidelines, and our administration actively \n322 supervises us.“\n323 - Epidemiologist, Hospital 3, ASP-introduced\n324\n325 \"....it would be better if we get involved, receive information and solve the problem \n326 together.” \n327 -Head Nurse, Hospital 4, ASP-introduced\n328\n329 “We have had good results since the beginning. Our fears did not come true and even one \n330 dose proved to be sufficient for preventive purposes. These are the results we have had so \n331 far.”\n332 - Surgeon, Hospital 1, ASP-introduced\n333\n334 Discussion\n335 The findings presented above highlight drivers supporting the ASP uptake in hospitals where it \n336 was introduced, and a few barriers potentially affecting longer-term ASP scale-up and \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309557doi: medRxiv preprint \n\n17\n337 sustainability. Findings primarily relate to epidemiologists’ and nurses’ ASP behaviours, perhaps \n338 in part because other target groups’ ASP roles did not differ significantly from their routine \n339 functions. \n340\n341 Firstly, participants across target groups appreciated the new dynamic in SAP prescribing \n342 introduced under the ASP, which encourages involvement of an interprofessional team. \n343 Broader research on SAP ASPs emphasizes how successful ASP implementation requires \n344 overcoming paternalism in decision-making and fostering interprofessional consultation.(15–\n345 17) Unlike counterparts at other hospitals, epidemiologists and nurses from ASP-introduced \n346 hospitals were respectively involved in SAP treatment planning and in patient follow-up. \n347 Research participants from both these groups valued the increased educational opportunities \n348 and concomitant professional development offered under the ASP, despite an indication of \n349 having increased workloads, and felt it successfully supported them in carrying out their roles. \n350 Their view echoes research on SAP ASPs that stresses the need to invest in health worker \n351 education to ensure their effective participation and consequently successful ASP \n352 implementation.(18–20)\n353\n354 Research also showed epidemiologists and nurses across all hospitals play an important role in \n355 SAP. ASP-participating hospital participants not only expressed this belief, but also explained \n356 ASP participation boosted their professional confidence. Nurses in particular mentioned this \n357 fact with regard to discussing AMR with patients. Global research illustrates epidemiologists are \n358 critical to ASP efforts in leadership support, sharing surveillance data or outbreak alerts, \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309557doi: medRxiv preprint \n\n18\n359 bridging gaps between departments, and treatment algorithm development.(19,21) Nurses, in \n360 turn, have been shown to be crucial across the health economy, especially in fostering health \n361 literacy of AMR through effective communication and education.(18,21) Investment in \n362 developing nurses’ AMR competencies could be particularly important in the Georgian context. \n363 As surgeon and administrator participants noted, while nurses played an important role in ASP, \n364 many did not have sufficient qualifications. This is corroborated by reporting that patient and \n365 health outcomes in Georgia are affected by a nursing shortage, affected by factors such as low \n366 wages, professional development opportunities, labour migration, and social stigma.(22–24)\n367\n368 Barriers to health worker ASP uptake related to the ASP delivery and health system context. \n369 Non-introduced hospital participants lacked awareness of the SAP project. This could be due to \n370 several factors, including staff turnover and limited communication on the ASP with the \n371 hospitals between the programme launch and introduction. The unavailability of national-level \n372 information on SSIs, combined with fines for not reporting and a lack of feedback to hospitals \n373 on SSI reporting, could impede longer-term reporting behaviour and limit access to up-to-date \n374 information to support appropriate SAP. While behaviour change interventions are effective to \n375 address AMR, wider health system level changes, such as effective SSI reporting and feedback, \n376 are necessary to support ASP scale-up and sustainability.(25,26)\n377\n378 Another factor cited as affecting long-term ASP sustainability was patients’ demand for and \n379 access to antibiotics OTC, leading to their disregard of doctors’ treatment advice. While public \n380 awareness of AMR is a widespread issue, nurses did report their ASP training equipped them \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309557doi: medRxiv preprint \n\n19\n381 with knowledge and skills to effectively communicate with patients on AMR and appropriate \n382 antibiotic use, which administrators indicated was a particular challenge. In this way, the ASP \n383 could address an important communication skills gap. Investing in training health workers is \n384 important. Public attitudes towards AMR in Georgia and elsewhere have been shown to be \n385 effectively addressed through education via schools or by health workers, whom the public see \n386 as trusted sources of health information, rather than solely via information campaigns.(8,27–\n387 29) \n388\n389 Two challenges limiting study results related to the time available for research and to \n390 navigating health worker concerns around participation. Resource constraints decreased the \n391 available time for research and analysis. To address this, time was allocated for researcher \n392 training on SAP and ASP, theoretical approaches for data collection and interpretation, \n393 conducting research and analysis, and collaborating with diverse research participants. Health \n394 workers, especially nurses, were new to participating in qualitative research, and despite \n395 providing informed consent, were concerned of being professionally assessed. This fact limited \n396 participants’ responses and, subsequently, information on motivation factors affecting \n397 participants’ behaviours. Nonetheless, almost all ASP participants were included in research, \n398 and findings provide relevant insights following other qualitative studies revealing SAP ASPs as \n399 affected by multiple factors. These include missed opportunities due to professional \n400 hierarchies, low health worker competencies or confidence, and unawareness of local AMR \n401 epidemiology.(15,30,31)\n402\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309557doi: medRxiv preprint \n\n20\n403 Conclusion\n404 Study findings indicate the introduction of interprofessional collaboration on SAP supported \n405 ASP uptake among all participants. Epidemiologists’ and nurses’ uptake was encouraged by the \n406 additional professional development opportunities provided under ASP and facilitated by \n407 increased SAP and AMR knowledge. Further inquiry should explore motivation factors \n408 supporting health workers' ASP uptake, which would require addressing health worker \n409 concerns on research participation.\n410\n411 Acknowledgements\n412 The authors would like to thank Marika Tsereteli (ICARS) for support and coordination on in-\n413 country research; David Chakhunashvili (NCDC) for support in researcher training; Marine \n414 Baidauri and colleagues at the MoIDPLHSA for clarifying questions arising from research; and \n415 Giorgi Kurtsikashvili (WHO Country Office in Georgia) and the leadership of the NCDC and \n416 MoIDPLHSA for coordination and support to the project. 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(which was not certified by peer review)\nThe copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309557doi: medRxiv preprint","source_license":"CC-BY-4.0","license_restricted":false}