Development of an intervention to support the implementation of evidence-based strategies for optimising antibiotic prescribing in general practice
Authors: Borek Aleksandra J. , Campbell Anne , Dent Elle , Moore Michael , Butler Christopher C. , Holmes Alison , Walker A. Sarah , McLeod Monsey , Tonkin-Crine Sarah ,   on behalf of the STEP-UP study team, Anyanwu Philip E. , Borek Aleksandra J. , Bright Nicole , Buchanan James , Butler Christopher C. , Campbell Anne , Costelloe Ceire , Hayhoe Benedict , Holmes Alison , Hopkins Susan , Majeed Azeem , McLeod Monsey , Moore Michael , Morrell Liz , Pouwels Koen B. , Robotham Julie V. , Roope Laurence S. J. , Tonkin-Crine Sarah , Walker Ann Sarah , Wordsworth Sarah , Wright Carla , Yadav Sara , Zalevski Anna 
Published: September 2021

Abstract
Background
Trials show that antimicrobial stewardship (AMS) strategies, including communication skills training, point-of-care C-reactive protein testing (POC-CRPT) and delayed prescriptions, help optimise antibiotic prescribing and use in primary care. However, the use of these strategies in general practice is limited and inconsistent. We aimed to develop an intervention to enhance uptake and implementation of these strategies in primary care.

Methods
We drew on the Person-Based Approach to develop an implementation intervention in two stages. (1) Planning and design: We defined the problem in behavioural terms drawing on existing literature and conducting primary qualitative research (nine focus groups) in high-prescribing general practices. We identified ‘guiding principles’ with intervention objectives and key features and developed logic models representing intended mechanisms of action. (2) Developing the intervention: We created prototype intervention materials and discussed and refined these with input from 13 health professionals and 14 citizens in two sets of design workshops. We further refined the intervention materials following think-aloud interviews with 22 health professionals.

Results
Focus groups highlighted uncertainties about how strategies could be used. Health professionals in the workshops suggested having practice champions, brief summaries of each AMS strategy and evidence supporting the AMS strategies, and they and citizens gave examples of helpful communication strategies/phrases. Think-aloud interviews helped clarify and shorten the text and user journey of the intervention materials. The intervention comprised components to support practice-level implementation: antibiotic champions, practice meetings with slides provided, and an ‘implementation support’ website section, and components to support individual-level uptake: website sections on each AMS strategy (with evidence, instructions, links to electronic resources) and material resources (patient leaflets, POC-CRPT equipment, clinician handouts).

Conclusions
We used a systematic, user-focussed process of developing a behavioural intervention, illustrating how it can be used in an implementation context. This resulted in a multicomponent intervention to facilitate practice-wide implementation of evidence-based strategies which now requires implementing and evaluating. Focusing on supporting the uptake and implementation of evidence-based strategies to optimise antibiotic use in general practice is critical to further support appropriate antibiotic use and mitigate antimicrobial resistance.