30
from the first evaluation of this program demonstrate promising results in reducing antibiotic use in LTCFs.30 Programs are more likely to influence practice if they target underlying barriers to change.31 The intervention mapping approach described has practical implications for guiding implementation of the program because it produces a clear rationale for why each strategy is important (ie, what specific barriers are being addressed), which can help LTCFs decide how to prioritize the implementation of the recommended strategies. The project team was able to consult with a specialist that
delivers training on the use of knowledge translation approaches, including implementation process models and frameworks. However, most of the work was conducted by project team members without previous experience with these approaches. Several accessible resources were available to guide this work that could support other teams follow a similar process.17,32 Existing reviews describing studies of interventions that aim to
reduce antibiotic prescribing for ASB have documented evidence of practice change31; however, the average effect sizes are underwhelming considering the magnitude of inappropriate prescribing of antibiotics in long-term care.6 Different approaches are needed to develop more impactful, sustainable antimicrobial stewardship programs. Programs have also targeted a narrow range of barriers and have placed a strong focus on addressing knowledge barriers.33 However, studies that have explored bar- riers to practice change around antibiotic prescribing practices have demonstrated that the issue is complex and requires a multifaceted approach to address a broader range of behavioral constructs to support change (eg, beliefs, emotions, reinforce- ment, environmental context and resources).14,21–23 Providing education and resources alone is often insufficient to support sustainable practice change. This report of a cross-sectional sur- vey plus focus groups contributes to the literature that has focused on understanding the root causes of overprescribing antibiotics in long-term care. In reflecting on the steps used to develop this program and
lessons learned, a few limitations should be considered during future pilot studies and iterations of the program. The program missed the opportunity to interact more directly with residents and families to inform a better understanding of their concerns around the management of UTIs and the types of support and resources they would have found valuable. A stakeholder survey was foundational for identifying several barriers and facilitators to practice change in this area; however, findings from this survey might not have been representative of challenges faced across all LTCFs interested in this program. A comprehensive evaluation plan that supports multiple iterations of this program can provide guidance on how it can be implemented in long-term care, what impact it can have, and how it can be improved to support LTCFs across the province that have identified a need to improve practice in this area. In conclusion, a number of important barriers relate to the overtreatment of ASB in LTCFs: gaps in knowledge and skills, lack of resources to guide decision making, poor documentation and communication of symptoms, absence of clear policies and procedures, lack of acceptance of best practice recommendations, fears that an infection will be missed, and a number of common practices that are reinforcing ongoing treatment of ASB. An intervention mapping approach using the TDF can be useful to identify multimodal approaches tailored to the population to advance the design and impact of antimicrobial stewardship initiatives.
Andrea Chambers et al
Acknowledgments. The authors would like to thank all the long-term care home stakeholders who provided valuable feedback on the design of this program.
Financial support. The program development process was funded through operational funds held by Public Health Ontario.
Conflicts of interest. The authors declare that they have no conflicts of interests related to this article.
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