Exploring challenges in implementing antimicrobial stewardship interventions across eight African nations: A multi case study

Abstract

Introduction: The Commonwealth Partnerships for Antimicrobial Stewardship (CwPAMS) programme, funded by the UK Department of Health and Social Care's Fleming Fund and managed by the Commonwealth Pharmacists Association (CPA) and Tropical Health and Education trust (THET), currently supports 24 health partnerships (HPs) developing and implementing antimicrobial stewardship (AMS) interventions in 73 health facilities across eight African countries: Ghana, Kenya, Malawi, Nigeria, Sierra Leone, Tanzania, Uganda, and Zambia. This study assesses the barriers and challenges experienced by HPs in designing and implementing AMS interventions. Method: A qualitative case-study design was adopted, with data collection undertaken between June 2023 and March 2024 by in-person (THET and CPA) visits. Data collection methods included non-participant observations, formal and informal feedback from key stakeholders, semi-structured interviews and focus groups. Interview guides were designed based on the Consolidated Framework for Implementation Research to encourage systematic data collection and reporting, track progress and identify barriers encountered during implementation of AMS interventions. Qualitative data underwent thematic analysis using NVivo 14®. Results: Since the introduction of CwPAMS, a total of 15 AMS committees, 52 Point Prevalence Surveys (PPS) on antimicrobial use, and 21 AMS action plans have been developed and established across 73 health facilities, with 884 healthcare professionals completing AMS training. Key barriers reported by HPs included: challenges in PPS data collection due to lack, or inadequacy, of electronic patient record systems; delays in permissions and approvals (e.g. ethical approval); competing priorities (e.g. institutional priorities vs quality improvement initiatives); limited funding; challenges with procurement of medicines/reagents; over-ambitious projects as well as monitoring and evaluation plans. Health facilities also reported obstacles in antibiogram development due to inadequate sample sizes, secondary to limited access to diagnostics, reagents and consumables. HPs reported issues such as inconsistent access to running water, costly laboratory reagents with short expiry dates, staff shortages, and antibiotic stockouts. Reluctance to behavior change (especially prescribing practices), as well as time required for behavior change while implementing AMS interventions, were also commonly cited as barriers by HPs. Discussion: Buy-in from multiple stakeholders across all levels and scope of practices have facilitated change management and supported implementation of AMS interventions. In addition, realignment of project plans when and where needed, as well as efforts to secure additional funding and resources are underway to address the challenges identified. Conclusion: Multi-case study analyses informed the customization of interventions and the development of real-time data driven strategies to address implementation obstacles, thereby facilitating the adoption, integration and uptake of AMS interventions within respective health facilities which, in due course, lead to desired outcomes