Using the theoretical domains framework to investigate clinicians’ behavioural determinants of antimicrobial prescribing in Qatar.

Introduction: A recent systematic review by Talkhan et al demonstrated the need for theoretically based behaviour change interventions in this area. [1] For development of such complex interventions, emphasis should be placed on using theory to systematically identify behavioural determinants of antimicrobial prescribing. Aim: To identify and quantify clinicians’ behavioural determinants of antimicrobial prescribing in Qatar. Methods: This cross-sectional survey is part of a multi-phase explanatory, sequential mixed methods PhD project in Qatar. Questionnaires were distributed (online and paper based) to all doctors (~4,000) and pharmacists (~400) within Hamad Medical Corporation (HMC, the main healthcare provider). The questionnaire was developed with reference to the Determinants of Implementation Behaviour Questionnaire (a generic questionnaire derived from the 14 theoretical domains of the Theoretical Domains Framework, TDF). [2] Each item was presented as a 5-point Likert scale (scored 5=Strongly agree to 1=Strongly disagree). Personal and practice demographics were also collected for data contextualisation. The draft questionnaire was reviewed for face/content validity by an expert panel of six researchers in Qatar and the UK with experience in the use of the TDF, followed by ‘Think aloud’ testing and piloting. Analysis investigated the behavioural determinants and influential factors through descriptive, principal component analysis (PCA) and inferential analysis. Ethics approval was granted from a UK university and HMC. Results: In total, 535 responses were received, 339 (63.4%) from doctors and 196 (36.6%) from pharmacists. Respondents were predominantly male, 346 (64.7%). Just over half (n=285, 53.3%) had ≤ 5 years’ experience as health professionals. PCA showed a three component (C) solution with components incorporating a number of questionnaire items labelled: ‘Guidelines compliance’ (C1 with 8 items), ‘Influences on prescribing’ (C2 with 7 items) and ‘Self-efficacy’ (C3 with 5 items) in prescribing/recommendation activity. A scale score for each respondent was calculated through summation of Likert scores for the relevant questionnaire items within each component. These scales had high internal reliability (Cronbach’s alpha all >0.7) showing consistency in response between component items indicating statistical appropriateness for developing scales. The median score (possible scale range, midpoint) for each scale was C1, 32 (8 to 40, 24), C2, 26 (7 to 35, 21) and C3, 20, (5 to 25, 15). By way of example Table 1 shows levels of agreement for items in C2. This shows lower levels of agreement than C1 scale with the median scale score (26) closer to the midpoint (21) indicating that respondents had less positive views. Inferential analysis using these scale scores and free text analysis is in progress. Conclusion: A theoretical basis was used throughout providing insights to behavioural determinants for the development of a theory-based behaviour change intervention. Preliminary results suggest that social influences, staff development and quality monitoring may be useful targets for behaviour change interventions to improve antimicrobial prescribing practice. Limitations include potential social desirability bias and focus on one healthcare organisation/country in the Middle East which may limit generalisability of findings. More in-depth exploration is required to select and test appropriate linked theory-based behaviour change techniques

Theoretical approaches in the development and evaluation of behaviour change interversions that improve clinicians' antimicrobial prescribing: a systematic review.

Antimicrobial resistance (AMR) and its threats have long been recognised. Many countries have developed antimicrobial stewardship programmes with strategies to optimise antimicrobial prescribing, minimise AMR and improve outcomes. There remains a need for behaviour change interventions at clinician level to promote appropriate prescribing. Theories should be used for developing and evaluating interventions to change human behaviour. Aim/Objectives: The aim of this review was to critically appraise, synthesise and present the available evidence for theoretical approaches in the development and evaluation of behaviour change interventions designed to improve clinicians' antimicrobial prescribing. Research Design and Methodology: The systematic review protocol was developed and registered with the International Prospective Register of Systematic Reviews (CRD42018098586). MEDLINE, PubMed, Cumulative Index of Nursing and Allied Health Literature, International Pharmaceutical Abstracts, PsycINFO, ScienceDirect, The Cochrane Database of Systematic Reviews, Centre for Reviews and Dissemination, Database of Abstracts of Reviews of Effectiveness, Joanna Briggs Institute Library and Google Scholar were searched for peer-reviewed, English-language studies investigating theoretically based behaviour change interventions designed to improve clinicians’ antimicrobial prescribing in any healthcare setting. Additional studies were obtained from the bibliographies of retrieved papers. Two review authors independently extracted data and assessed study quality. Clinical and methodological heterogeneity limited data synthesis. Results: The searches resulted in 4227 potentially relevant papers after duplicates removal. Screening of titles/abstracts led to retrieval and dual assessment of 38 full-text papers. Of those, a total of 14 studies (4 qualitative, 5 quantitative and 5 mixed-methods) met the inclusion criteria and were included in the systematic review. Most of studies included were from the UK (n = 8) and most were published in 2008 and in 2017 (n = 6); none was published before 2008. The majority of studies were carried out in primary care settings (n = 10) targeting upper respiratory tract infections (n = 7). Theoretical approaches used to inform the design and choice of intervention varied across included studies. The most common included: Theory of Planned Behaviour, Social Cognitive Theory and Operant Learning Theory. Conclusion/Discussion: This systematic review is the first to investigate theoretically based behaviour change interventions for antimicrobial prescribing. Only a small number of primary research studies involving theory in intervention development and evaluation were identified. There is a need for further research in this area. Restricting the review to papers published in English may have been a limitation

Rabies Virus Populations in Humans and Mice Show Minor Inter-Host Variability within Various Central Nervous System Regions and Peripheral Tissues

Rabies virus (RABV) has a broad host range and infects multiple cell types throughout the infection cycle. Next-generation sequencing (NGS) and minor variant analysis are powerful tools for studying virus populations within specific hosts and tissues, leading to novel insights into the mechanisms of host-switching and key factors for infecting specific cell types. In this study we investigated RABV populations and minor variants in both original (non-passaged) samples and in vitro-passaged isolates of various CNS regions (hippocampus, medulla oblongata and spinal cord) of a fatal human rabies case, and of multiple CNS and non-CNS tissues of experimentally infected mice. No differences in virus populations were detected between the human CNS regions, and only one non-synonymous single nucleotide polymorphism (SNP) was detected in the fifth in vitro passage of virus isolated from the spinal cord. However, the appearance of this SNP shows the importance of sequencing newly passaged virus stocks before further use. Similarly, we did not detect apparent differences in virus populations isolated from different CNS and non-CNS tissues of experimentally infected mice. Sequencing of viruses obtained from pharyngeal swab and salivary gland proved difficult, and we propose methods for improving sampling

First molecular analysis of rabies virus in Qatar and clinical cases imported into Qatar, a case report

Identifying the origin of the rabies virus (RABV) infection may have significant implications for control measures. Here, we identified the source of a RABV infection of two Nepalese migrants in Qatar by comparing their RABV genomes with RABV genomes isolated from the brains of a RABV infected camel and fox from Qatar

Letter to the editor: Injured Libyan combatant patients: Both vectors and victims of multiresistance bacteria?

No Abstract

Invasive Amoebiasis complicating Inflammatory Bowel Disease

No Abstrac