Investigating the cultural and contextual determinants of antimicrobial stewardship programmes across low-, middle- and high-income countries-A qualitative study
Investigating the cultural and contextual determinants of antimicrobial stewardship programmes across low-, middle- and high-income countries-A qualitative study
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DOI：
10.1371/journal.pone.0209847
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发表时间：
2019-01-16
期刊：
影响因子：
3.7
通讯作者：
Holmes, Alison Helen
中科院分区：
文献类型：
--
作者：
Charani, Esmita;Smith, Ingrid;Holmes, Alison Helen
背景抗菌药物管理计划（ASP）有助于维持抗菌药物有效性的大多数证据都是在高收入国家产生的。我们报告了一项研究，调查ASP在低收入、中等收入和高收入国家的二级保健中的实施情况。本研究的目的是映射的关键上下文，包括文化，驱动程序的开发和实施ASP在不同的resource settings.Materials和methodsHealthcare专业人员负责实施ASP在英国，法国，挪威，印度和布基纳法索的医院被邀请参加面对面的采访。从观察，文件证据和访谈记录的现场记录进行了分析，采用扎根理论的方法。采用不断比较、初始编码、返回现场进一步收集数据和重点编码等方法，对关键的新出现类别进行反复分析。应用理论抽样，直到类别饱和。结果共访问了24家医院的54名参与者（英国9名参与者/4家医院;挪威13名参与者/4家医院;法国9名参与者/7家医院;印度13名参与者/7家医院;布基纳法索8名参与者/2家医院）。在挪威、法国和英国，ASP结构是一致的。在印度和布基纳法索，ASP存在国家一级的异质性。国家对ASP的支持在缺乏支持的国家（印度、布基纳法索）被认为是至关重要的，而在存在支持的国家，支持被认为是一种障碍（英国、法国）。专业界限是决定参与ASP中公认为领导者的医生倡议的关键文化决定因素之一。护士和药剂师的参与仅限于英格兰。在每个国家，外科专业都被认为是最难接触的。尽管面临挑战，在印度的一家医院提供了最好的例子，跨学科的ASP，倡导通过organizational leadership.ConclusionsASP倡议在这项研究中受到限制的专业界限和层次结构，缺乏参与更广泛的医疗保健劳动力。有必要促进跨学科的团队工作，包括药剂师和护士，这取决于不同国家的医疗保健劳动力，在ASP。手术路径仍然是一个难以达到的，但全球ASP的关键目标。有必要在不同的资源环境中开发针对手术路径的上下文驱动的ASP。
BackgroundMost of the evidence on antimicrobial stewardship programmes (ASP) to help sustain the effectiveness of antimicrobials is generated in high income countries. We report a study investigating implementation of ASP in secondary care across low-, middle- and high-income countries. The objective of this study was to map the key contextual, including cultural, drivers of the development and implementation of ASP across different resource settings.Materials and methodsHealthcare professionals responsible for implementing ASP in hospitals in England, France, Norway, India, and Burkina Faso were invited to participate in face-to face interviews. Field notes from observations, documentary evidence, and interview transcripts were analysed using grounded theory approach. The key emerging categories were analysed iteratively using constant comparison, initial coding, going back the field for further data collection, and focused coding. Theoretical sampling was applied until the categories were saturated. Cross-validation and triangulation of the findings were achieved through the multiple data sources.Results54 participants from 24 hospitals (England 9 participants/4 hospitals; Norway 13 participants/4 hospitals; France 9 participants/7 hospitals; India 13 participants/7 hospitals; Burkina Faso 8 participants/2 hospitals) were interviewed. Across Norway, France and England there was consistency in ASP structures. In India and Burkina Faso there were country level heterogeneity in ASP. State support for ASP was perceived as essential in countries where it is lacking (India, Burkina Faso), and where it was present, it was perceived as a barrier (England, France). Professional boundaries are one of the key cultural determinants dictating involvement in initiatives with doctors recognised as leaders in ASP. Nurse and pharmacist involvement was limited to England. The surgical specialty was identified as most difficult to engage with in each country. Despite challenges, one hospital in India provided the best example of interdisciplinary ASP, championed through organisational leadership.ConclusionsASP initiatives in this study were restricted by professional boundaries and hierarchies, with lack of engagement with the wider healthcare workforce. There needs to be promotion of interdisciplinary team work including pharmacists and nurses, depending on the available healthcare workforce in different countries, in ASP. The surgical pathway remains a hard to reach, but critical target for ASP globally. There is a need to develop contextually driven ASP targeting the surgical pathway in different resource settings.