A qualitative study on factors influencing health workers’ uptake of a pilot surgical antibiotic prophylaxis stewardship programme in selected Georgian hospitals

1 1 Title: A qualitative study on factors influencing health 2 workers’ uptake of a pilot surgical antibiotic prophylaxis 3 stewardship programme in selected Georgian hospitals 4 5 Short Title: Factors influencing pilot SAP stewardship 6 uptake in Georgia 7 8 Sideeka Narayan1, Sahil Khan Warsi1*, Iago Kachkachishvili2, Osiko Kontselidze2, Mariam 9 Jibuti 2, Nino Esebua2, Ana Papiashvili2, Danilo Lo Fo Wong1, Ketevan Kandelaki1* 10 11 1 World Health Organization (WHO) Regional Office for Europe, Copenhagen, Denmark 12 2 Institute of Social Studies and Analysis, Tbilisi, Georgia 13 14 * Corresponding authors 15 E-mail: [email protected] (KK) 16 [email protected] (SKW) 17 18 SN: writing original draft, review and editing, formal analysis 19 SKW: conceptualization, methodology, writing original draft, review and editing, formal 20 analysis, resources, supervision 21 IK: project administration, methodology, data curation, formal analysis, resources 22 OK: data curation, formal analysis, visualization 23 MJ: data curation, formal analysis, visualization 24 NE: data curation, formal analysis, visualization 25 AP: data curation, formal analysis, visualization 26 DLFW: project administration, supervision 27 KK: conceptualization, methodology, writing original draft, review and editing, formal analysis, 28 resources, supervision . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309557doi: medRxiv preprint NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice. 2 29 Abstract 30 Antimicrobial misuse in surgical antibiotic prophylaxis (SAP) can include the inappropriate use 31 of broad-spectrum antibiotics or prolonged dosing. In 2021, a pilot antimicrobial stewardship 32 programme (ASP) was launched in Georgia, which involved developing and adapting SAP 33 guidelines, establishing an interprofessional SAP prescribing approach, collecting surgical site 34 infection (SSI) data via routinely collected data and telephonic patient follow-ups, and providing 35 surgical unit staff with prescribing feedback and training on antimicrobial resistance (AMR) and 36 antimicrobial stewardship (AMS). ASP introduction was staggered across ten hospitals over 37 three years. 38 39 This study explored behavioural determinants of surgical teams’ ASP uptake in five hospitals 40 where the ASP was introduced or about to be introduced. Findings primarily concerned 41 epidemiologists’ and nurses’ ASP-related behaviour. Those at ASP non-introduced hospitals 42 were less involved in the SAP prescribing process, had lower AMR awareness, and lacked 43 professional development opportunities. Those at ASP-introduced hospitals exhibited higher 44 AMR knowledge and felt ASP participation boosted confidence, facilitated work, and furnished 45 key professional development. 46 47 Results indicate interprofessional collaboration on SAP prescribing supported ASP uptake across 48 teams, and investment in health worker training and administrative encouragement ensured 49 effective ASP participation and implementation. Findings highlight the crucial role of 50 epidemiologists in SAP and illustrate a need for developing Georgian nurses’ AMR . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309557doi: medRxiv preprint 3 51 competencies as a vehicle to address public AMR knowledge gaps. Longer-term ASP uptake will 52 need to consider the regulatory context in which hospitals lack access to national-level SSI data 53 and feedback on SSI reporting but are fined for reporting non-compliance. 54 55 Despite resource limitations and a small sample size, the study engaged all pilot ASP health 56 workers. Respondents’ inexperience of qualitative research participation and ensuant hesitation 57 limited exploration of motivational factors supporting health workers' ASP uptake, which could 58 be explored in further research. 59 60 Introduction 61 Antimicrobial resistance (AMR) is a global threat to public health. AMR occurs when 62 microorganisms, such as bacteria, viruses, parasites and fungi, change so that they are no 63 longer affected by antimicrobial medicines used to treat them. The development and spread of 64 AMR is accelerated by the inappropriate use of antimicrobials, resulting in harder-to-treat 65 infections.(1–3) The misuse of antimicrobials in health-care settings is one of the key modifiable 66 drivers of the emergence of AMR. This issue deserves particular attention in surgical wards 67 where antibiotic prophylaxis is routinely administered prior to surgery to help decrease the risk 68 of postoperative infections. Addressing surgical antibiotic prophylaxis (SAP) requires an 69 appreciation and understanding of the behavioural and cultural context influencing health-care 70 professionals’ practices and decisions. 71 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309557doi: medRxiv preprint 4 72 Antimicrobial stewardship programmes (ASPs) are one of the most cost-effective interventions 73 to optimize antimicrobial use, improve patient outcomes, and reduce the development and 74 spread of AMR.(4,5) It involves a systematic approach to educate and support health-care 75 professionals to follow evidence-based guidelines for prescribing and administering 76 antimicrobials. Educating the health workforce is crucial, as they are key in safeguarding 77 antimicrobial effectiveness. Successful ASPs not only equip practitioners with information, but 78 do so by attending to the behavioural factors affecting programme uptake.(6,7) 79 80 In Georgia, as in other countries, the inappropriate use of antibiotics, including for surgical 81 prophylaxis, is characterized by a high use of broad-spectrum antibiotics and prolonged 82 dosing.(8–10) Actions to contain the development and spread of AMR in Georgia have thus far 83 mainly focused on strengthening AMR surveillance systems and implementing modern methods 84 for infection prevention and control (IPC). However, limited actions have been implemented to 85 establish ASPs and understand the factors affecting their uptake among health 86 professionals.(11,12) 87 88 In 2021, as part of Georgia’s 2017–2020 National action plan (NAP) to contain the spread of AMR, 89 the International Centre for Antimicrobial Resistance Solutions (ICARS) began a three-year ASP 90 to develop and introduce SAP guidelines in ten hospitals, aiming for 60% hospital guideline 91 compliance within 12 months from ASP introduction. The ASP involved AMR and antimicrobial 92 stewardship (AMS) training for surgical unit staff; data collection on surgical site infection (SSI) 93 rates via post-surgical patient telephone interviews, and on antibiotic prescribing via monthly . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309557doi: medRxiv preprint 5 94 point prevalence surveys (PPS); and feedback to surgical teams to adjust prescribing practice. 95 Regarding health worker behaviours, the ASP primarily involved surgeons following new SAP 96 guidelines, epidemiologists conducting PPS, and nurses conducting post-surgical patient 97 interviews. The Ministry of Internally Displaced Persons from the Occupied Territories, Labor, 98 Health and Social Affairs of Georgia (MoIDPLHSA) and ICARS signed a memorandum of 99 understanding in September 2021, followed by an official project launch where ASP participating 100 staff at all ten hospitals were informed on ASP objectives and timelines and their specific roles. 101 ASP introduction was planned to begin in 2022 in overlapping stages for three hospitals in year 102 1, four in year 2, and three in year 3. 103 104 In collaboration with the MoIDPLHSA and National Centre for Disease Control (NCDC), the WHO 105 Regional Office for Europe (Regional Office) and WHO Country Office in Georgia undertook a 106 study in 2022 to identify barriers to and enablers for implementing the ICARS ASP during the first 107 year of its introduction. The study was conducted in parallel to the ICARS ASP and followed the 108 WHO Regional Office Tailoring Antimicrobial Resistance Programmes (TAP) method to identify 109 barriers to and drivers of behaviours contributing to ASP uptake. National researchers from the 110 Institute of Social Studies and Analysis (ISSA) conducted fieldwork across selected participating 111 hospitals to understand factors affecting health workers’ ASP-related behaviours. 112 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309557doi: medRxiv preprint 6 113 Methods 114 Study design and setting 115 Data collection and analysis were conducted using the Capability, opportunity, and motivation 116 for behaviour change (COM-B) theory, which is part of the Behaviour change wheel (BCW) 117 framework to understand and evaluate health-related behaviour interventions.(13) The COM-B 118 theory is built on a review of 19 existing behaviour change frameworks, and holds that public 119 health behaviour change is influenced by the interlinked factors of individuals’ capability, 120 opportunity, and motivation to enact specific behaviours. Fig. 1 below illustrates how the COM- 121 B factors are approached through TAP.(14) 122 123 Fig 1. The COM-B model adapted to AMR 124 125 The COM-B theory was employed to understand the behaviour of each target group outlined 126 below in relation to their function under or related to the ICARS ASP. Across the target groups, 127 the behaviours explored included SAP prescribing and adherence to guidelines, conducting ASP- 128 related surveillance and feedback, and integrating the ASP in hospital and surgical team practice. 129 The behaviours explored for each target group are presented in Table 1 in the results section 130 below. 131 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309557doi: medRxiv preprint 7 132 Data was collected in 2022 from five of the ten hospitals. The research sites represented regional 133 and hospital variation. Three hospitals were selected from Tbilisi and two from the regions, 134 representing a large private, smaller private, teaching, maternity, and military hospital. 135 136 Research participants 137 The primary target groups were the ICARS ASP team at each hospital: one hospital administrator, 138 one AMR champion, one epidemiologist, one surgical unit chief nurse and surgeons. In two 139 hospitals, the hospital administrator or AMR champion was also a surgeon. In such cases, the 140 individual participated in research in their administrator or AMR champion capacity and 141 additional questions were also asked relating to their role as a surgeon. Research was also 142 conducted with secondary target groups affecting the behaviour of primary target group 143 participants. This included a clinical pharmacist, health professional association representatives, 144 and pharmaceutical company representatives. Primary target group participants were sampled 145 to include the entire ASP team at each hospital, and secondary target group participants were 146 purposively sampled based on their availability and accessibility. Participants were recruited into 147 the study from 1 May to 1 July 2022. All participants received information on research and were 148 given the chance to ask questions before providing written and verbal consent to participate. The 149 study was conducted in accordance with the Helsinki Declaration (1964, revised 2013), and 150 received ethical approval from the WHO Research Ethics Committee, protocol number 151 ERC.0003668, and the Institutional Review Board of the National Center for Disease Control and 152 Public Health of Georgia, IRB number 2021-066. 153 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309557doi: medRxiv preprint 8 154 Data collection and analysis 155 Given that only one participant in each target group was engaged in the ASP at each hospital, 156 data was almost entirely collected via semi-structured, in-depth interviews (IDIs). Only one focus 157 group discussion (FGD) was conducted with surgeons from the three Tbilisi hospitals. IDIs and 158 the FGD were conducted using research guides, with questions developed via a COM-B-inspired 159 activity organized by the WHO Regional Office with the participation of representatives from 160 ICARS, NCDC, MoIDPLHSA, and the ASP hospitals. Questions addressed individuals’ knowledge 161 and perceptions of AMR and SAP, views on the ASP, and factors affecting ASP incorporation into 162 hospital practice. The guides were initially developed in English and then translated to Georgian. 163 164 Prior to data collection, the WHO Regional Office, ICARS and NCDC researchers conducted a 165 week-long workshop with the national research team. During this workshop, national 166 researchers were informed about the Georgian context of SAP and SSIs, the health system 167 context of Georgia, and trained on COM-B theory and its use in research, data collection, and 168 analysis. National researchers, jointly with WHO Regional Office, ICARS and NCDC 169 representatives, reviewed each research guide, line-by-line, for linguistic and contextual 170 appropriateness, and simultaneously adapted Georgian- and English-language versions to ensure 171 coherence across all guides. The guides were then piloted before research to ensure feasibility. 172 173 All discussions were audio-recorded and transcribed in Georgian before analysis. Transcripts 174 were anonymized using participant IDs, ensuring no identifying details were included. As WHO 175 Regional Office researchers could not be present during the initial stage of data collection, four . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309557doi: medRxiv preprint 9 176 initial transcripts were translated in English and shared with them for feedback and for 177 preliminary analysis training. A coding framework was developed based on sections of the 178 research guides. National and WHO Regional Office researchers coded two initial transcripts 179 separately and then compared results to identify differences. Based on these results, feedback 180 was provided to national researchers and the coding framework was adapted to allow for 181 emerging themes across transcripts. A second round of analysis was conducted with the 182 remaining two English transcripts, with almost identical coding by all researchers. After this 183 exercise, all transcripts were then coded and analysed directly from Georgian by national 184 researchers. 185 186 Coded data, observations, and quotations were organized into a Microsoft Excel spreadsheet for 187 each target group in Georgian. National researchers developed a thematic report based on 188 analysed data which was used by WHO Regional Office researchers to conduct a COM-B analysis 189 of research findings by target group and hospital type. 190 191 Results 192 A total of 26 IDIs and one FGD were conducted with 31 participants from five hospitals. At the 193 time of data collection, the ASP had been introduced in three of the five hospitals. Findings on 194 factors affecting ASP uptake show similarities across target groups as well as differences 195 between ASP-introduced and non-introduced hospitals. Primary COM-B factor findings are 196 presented below, and an overview of participants by target group, ASP-related behaviours and 197 research activities are presented in Table 1. . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309557doi: medRxiv preprint 10 198 199 Table 1. Participants by target group, ASP-related behaviour, and research activity Target group ASP-related behaviour Research activity Total participants Primary target group (ASP participants) Hospital administrator Leads adoption and dissemination of SAP guidelines and ASP introduction IDI 4 Hospital AMR champion Coordinates ASP introduction, data collection/analysis and feedback IDI 3 FGD 5Surgeons Receive training and use developed SAP guidelines IDI 5 Epidemiologists Collect and analyse SSI/PPS data for SAP ASP IDI 5 Study nurse Collects SSI data from post- surgery patients IDI 5 Secondary target group (influencers) Hospital pharmacists Influence antibiotic availability and prescribing process IDI 1 Professional association representatives Influence behaviour of primary target group professionals IDI 2 Pharmaceutical company representatives Directly advertise and provide antibiotics to hospitals IDI 1 Total 31 200 201 Behaviour 202 ASP-introduced hospital participants reported active involvement in ASP activities, while ASP 203 non-introduced hospitals’ participants had limited involvement in similar activities. Variation 204 was primarily observed across hospitals in epidemiologist and nurse involvement in SAP. 205 Epidemiologists at all hospitals reported conducting surveillance on health-care associated 206 infections (HAIs), trainings on issues such as hand hygiene and disinfection-sterilization or HAI . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309557doi: medRxiv preprint 11 207 reporting to NCDC. ASP-introduced hospital epidemiologists supervised medical staff on and 208 monitored antibiotic prescription for guideline compliance. Conversely, ASP-non-introduced 209 hospital epidemiologists were not involved in antibiotic selection or the prescribing process but 210 believed they should be. 211 "As for monitoring the use of antibiotics, I do not monitor what antibiotic the doctor 212 prescribed and how. We talked about this issue with the quality service, that it is better if we 213 get more actively involved in the issue. We have a plan to take one in ten cases and check if 214 antibiotics have been prescribed according to the guideline.” 215 – Epidemiologist, Hospital 1, ASP non-introduced 216 217 Nurses in Georgia administer prescribed antibiotics and supervise therapy; they do not have the 218 right to prescribe. ASP-introduced hospital nurses were more involved in patients’ treatment, 219 regularly communicating with them and providing information on AMR and the ASP. They 220 interviewed patients one-week and one-month post-surgery, recording information on 221 prescription and non-prescription antibiotic use, complaints and complications. ASP non- 222 introduced hospital nurses were not involved in such activities. 223 224 Significant behavioural differences across hospitals were not observed for other target groups. 225 Surgeons develop patients’ antibiotic treatment plans in consultation with other specialties, 226 although one ASP non-introduced hospital administrator indicated some staff might rely on 227 experience rather than evidence-based guidelines. Administrators, in general, ensure the 228 quality and safety of patient care and implement treatment guidelines and monitor their . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309557doi: medRxiv preprint 12 229 compliance. The AMR champion role was created for ASP; the majority of those in this role 230 were already engaged in some form of administration or treatment strategizing. 231 232 Capability 233 Although all participants were informed via the 2021 ASP launch, most ASP non-introduced 234 hospital participants were unaware of their hospital’s participation and their roles. Differences 235 in knowledge, skills and training were specifically observed among nurses and epidemiologists. 236 Surgeons stated nurses lack required ASP competencies. A professional association 237 representative reported AMR knowledge gaps among epidemiologists, citing insufficient up-to- 238 date information and confirmed by ASP non-introduced hospital epidemiologists’ unfamiliarity 239 with the Access, watch, reserve (AWaRe) classification. ASP non-introduced nurses and 240 epidemiologists expressed an interest to participate in trainings to strengthen knowledge of 241 AMR and the ASP. 242 243 ASP-introduced hospital epidemiologists and nurses felt confident in their skills and reported 244 significant improvement as a result of ASP trainings. Nurses expressed increased AMR and SAP 245 knowledge, which facilitated patient communication, and believed the additional ASP duties 246 and understanding of AMR were interesting and important for professional development. 247 Administrators added that extra communication was often required for patients and their 248 families to encourage appropriate antibiotic use. Epidemiologists demonstrated awareness of 249 the AWaRe classification and proactive use of guidelines, reporting this as an important tool for 250 effective monitoring and supportive to their work. . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309557doi: medRxiv preprint 13 251 “There were several cases when the doctor did not prescribe an antibiotic, but the patient 252 replied that they still take it on their own. They even had complaints about it. They still think 253 it is impossible for the treatment to go well without antibiotics.” 254 - Nurse, Hospital 5, ASP-introduced 255 256 A few capability findings related to participants’ perceptions. Regarding SAP guideline 257 application, some ASP non-introduced hospital administrators and surgeons believed a 258 consultative approach to patient antibiotic treatment planning was not necessary as national 259 guidelines outlined available options. Epidemiologists perceived their facility’s SSI incidence was 260 low at one to two cases per year. 261 “We don't need to consult with colleagues [such as infectious disease specialists] on which 262 antibiotic to use or replace. The Ministry has given us [SAP Guidelines] with the names of only 263 two antibiotics.” 264 -Surgeon, Hospital 1, ASP non-introduced 265 266 Opportunity 267 ASP-introduced hospital participants reported that the hospital-specific adaptation of national 268 SAP guidelines and introduction of the digital patient recording system facilitated antibiotic 269 treatment and planning. Several ASP-introduced hospital participants mentioned an initial 270 increase in workload following ASP introduction but reported that this was integrated into 271 routine practice. . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309557doi: medRxiv preprint 14 272 “…protocols developed will help health-care facilities use antibiotics more rationally. Besides, 273 we, as doctors, will obtain knowledge and will disseminate it within the facility... Some 274 surgeons are employed at several [other] hospitals and will disseminate the knowledge there 275 as well. “ 276 -AMR champion, Hospital 4, ASP-introduced 277 While epidemiologists across all hospitals mentioned having continuous medical education 278 opportunities on various topics, ASP non-introduced hospital epidemiologists and nurses 279 reported not receiving AMR-specific training. AMR champions at ASP-introduced hospitals 280 further reported ASP communication was presented to all services, and that SAP conferences 281 and trainings were open to all staff, broadening staff involvement and exposure to the ASP. One 282 epidemiologist said ASP scale-up and sustainability would depend on government enforcement 283 through integration in national health plans. 284 285 Opportunity barriers reported by epidemiologists related to reporting on SSIs. They do not have 286 access to national-level information on SSIs. Additionally, while hospitals do not receive 287 feedback from NCDC on SSI reporting, they are fined for non-compliance with reporting 288 regulations. 289 “In case of HAIs we report what went wrong and why HAI developed. We have no feedback 290 but, in case of non-compliance with regulations, the clinic might be fined.” 291 - Epidemiologist, Hospital 5, ASP-introduced 292 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309557doi: medRxiv preprint 15 293 Participants cited the lack of public AMR awareness and demand for antibiotics as a social 294 opportunity barrier. They added that patients could deviate from doctors’ advice by buying 295 over-the-counter (OTC) antibiotics. Relatedly, an AMR champion emphasized treatment plans 296 must be effectively communicated to patients to increase treatment compliance and 297 confidence. ASP-introduced hospital nurses further reported that patients positively responded 298 to follow-up calls providing information on AMR, with only few becoming suspicious or anxious 299 about their health. 300 “[One challenge] is that the patient or their family member demands antibiotics… we 301 convince them that it’s not needed. We inform them about the possible side-effects of 302 inappropriate use of antibiotics… The majority of patients are satisfied when you call them 303 after the surgery to check on them … in rare cases… even though they are informed in 304 advance to expect two calls, they can become suspicious.” 305 - Nurse, Hospital 1, ASP-introduced 306 307 “If the information is communicated correctly to the patients and the results are also 308 favourable, the patient will go along with you. I think it is always possible to overcome 309 stereotypes if you try. “ 310 - AMR champion, Hospital 4, ASP-introduced 311 312 Motivation 313 Participants across target groups reported initial hesitancy to the ASP, related to workload, 314 effectiveness, patient acceptance, and other factors. However, they indicated that hospital . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309557doi: medRxiv preprint 16 315 context influenced the willingness and ability to support and participate in the ASP. ASP- 316 introduced hospital administrators reported the programme strengthened staff knowledge and 317 responsibility. Nurses and epidemiologists specifically welcomed such qualification-raising 318 opportunities and believed they are integral to ASP implementation. Epidemiologists also 319 believed that administrators play a role in encouraging ASP acceptance and adherence. 320 “The initial attitude was skeptical. However, it was seen that the [SAP] was successful…This 321 requirement has been strengthened by the guidelines, and our administration actively 322 supervises us.“ 323 - Epidemiologist, Hospital 3, ASP-introduced 324 325 "....it would be better if we get involved, receive information and solve the problem 326 together.” 327 -Head Nurse, Hospital 4, ASP-introduced 328 329 “We have had good results since the beginning. Our fears did not come true and even one 330 dose proved to be sufficient for preventive purposes. These are the results we have had so 331 far.” 332 - Surgeon, Hospital 1, ASP-introduced 333 334 Discussion 335 The findings presented above highlight drivers supporting the ASP uptake in hospitals where it 336 was introduced, and a few barriers potentially affecting longer-term ASP scale-up and . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309557doi: medRxiv preprint 17 337 sustainability. Findings primarily relate to epidemiologists’ and nurses’ ASP behaviours, perhaps 338 in part because other target groups’ ASP roles did not differ significantly from their routine 339 functions. 340 341 Firstly, participants across target groups appreciated the new dynamic in SAP prescribing 342 introduced under the ASP, which encourages involvement of an interprofessional team. 343 Broader research on SAP ASPs emphasizes how successful ASP implementation requires 344 overcoming paternalism in decision-making and fostering interprofessional consultation.(15– 345 17) Unlike counterparts at other hospitals, epidemiologists and nurses from ASP-introduced 346 hospitals were respectively involved in SAP treatment planning and in patient follow-up. 347 Research participants from both these groups valued the increased educational opportunities 348 and concomitant professional development offered under the ASP, despite an indication of 349 having increased workloads, and felt it successfully supported them in carrying out their roles. 350 Their view echoes research on SAP ASPs that stresses the need to invest in health worker 351 education to ensure their effective participation and consequently successful ASP 352 implementation.(18–20) 353 354 Research also showed epidemiologists and nurses across all hospitals play an important role in 355 SAP. ASP-participating hospital participants not only expressed this belief, but also explained 356 ASP participation boosted their professional confidence. Nurses in particular mentioned this 357 fact with regard to discussing AMR with patients. Global research illustrates epidemiologists are 358 critical to ASP efforts in leadership support, sharing surveillance data or outbreak alerts, . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309557doi: medRxiv preprint 18 359 bridging gaps between departments, and treatment algorithm development.(19,21) Nurses, in 360 turn, have been shown to be crucial across the health economy, especially in fostering health 361 literacy of AMR through effective communication and education.(18,21) Investment in 362 developing nurses’ AMR competencies could be particularly important in the Georgian context. 363 As surgeon and administrator participants noted, while nurses played an important role in ASP, 364 many did not have sufficient qualifications. This is corroborated by reporting that patient and 365 health outcomes in Georgia are affected by a nursing shortage, affected by factors such as low 366 wages, professional development opportunities, labour migration, and social stigma.(22–24) 367 368 Barriers to health worker ASP uptake related to the ASP delivery and health system context. 369 Non-introduced hospital participants lacked awareness of the SAP project. This could be due to 370 several factors, including staff turnover and limited communication on the ASP with the 371 hospitals between the programme launch and introduction. The unavailability of national-level 372 information on SSIs, combined with fines for not reporting and a lack of feedback to hospitals 373 on SSI reporting, could impede longer-term reporting behaviour and limit access to up-to-date 374 information to support appropriate SAP. While behaviour change interventions are effective to 375 address AMR, wider health system level changes, such as effective SSI reporting and feedback, 376 are necessary to support ASP scale-up and sustainability.(25,26) 377 378 Another factor cited as affecting long-term ASP sustainability was patients’ demand for and 379 access to antibiotics OTC, leading to their disregard of doctors’ treatment advice. While public 380 awareness of AMR is a widespread issue, nurses did report their ASP training equipped them . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309557doi: medRxiv preprint 19 381 with knowledge and skills to effectively communicate with patients on AMR and appropriate 382 antibiotic use, which administrators indicated was a particular challenge. In this way, the ASP 383 could address an important communication skills gap. Investing in training health workers is 384 important. Public attitudes towards AMR in Georgia and elsewhere have been shown to be 385 effectively addressed through education via schools or by health workers, whom the public see 386 as trusted sources of health information, rather than solely via information campaigns.(8,27– 387 29) 388 389 Two challenges limiting study results related to the time available for research and to 390 navigating health worker concerns around participation. Resource constraints decreased the 391 available time for research and analysis. To address this, time was allocated for researcher 392 training on SAP and ASP, theoretical approaches for data collection and interpretation, 393 conducting research and analysis, and collaborating with diverse research participants. Health 394 workers, especially nurses, were new to participating in qualitative research, and despite 395 providing informed consent, were concerned of being professionally assessed. This fact limited 396 participants’ responses and, subsequently, information on motivation factors affecting 397 participants’ behaviours. Nonetheless, almost all ASP participants were included in research, 398 and findings provide relevant insights following other qualitative studies revealing SAP ASPs as 399 affected by multiple factors. These include missed opportunities due to professional 400 hierarchies, low health worker competencies or confidence, and unawareness of local AMR 401 epidemiology.(15,30,31) 402 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 27, 2024. ; https://doi.org/10.1101/2024.06.26.24309557doi: medRxiv preprint 20 403 Conclusion 404 Study findings indicate the introduction of interprofessional collaboration on SAP supported 405 ASP uptake among all participants. Epidemiologists’ and nurses’ uptake was encouraged by the 406 additional professional development opportunities provided under ASP and facilitated by 407 increased SAP and AMR knowledge. Further inquiry should explore motivation factors 408 supporting health workers' ASP uptake, which would require addressing health worker 409 concerns on research participation. 410 411 Acknowledgements 412 The authors would like to thank Marika Tsereteli (ICARS) for support and coordination on in- 413 country research; David Chakhunashvili (NCDC) for support in researcher training; Marine 414 Baidauri and colleagues at the MoIDPLHSA for clarifying questions arising from research; and 415 Giorgi Kurtsikashvili (WHO Country Office in Georgia) and the leadership of the NCDC and 416 MoIDPLHSA for coordination and support to the project. Additionally, we would like to thank 417 Paul Csagoly for his contributions to the editing of the manuscript. 418 Disclaimer: The authors affiliated with the World Health Organization (WHO) are alone 419 responsible for the views expressed in this publication and they do not necessarily represent 420 the decisions or policies of the WHO. 421 . 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