Table 4 Overview of CFIR constructs that were addressed in studies as barriers or facilitators

1

A

Intervention source

6

Local stakeholders were involved in intervention development to ensure ownership, buy-in, and participation.

B

Evidence strength & quality

9

Local data on AMR patterns was needed to guide the development of recommendations and guidelines, but it was difficult to obtain reliable AMR data in LMIC settings.

8

The intervention (e.g., guidelines and education material) was developed by authoritative and credible sources.

Guidelines developed based on local AMR pattern, available resources and needs of implementation facilities.

D

Adaptability

7

Intervention material was designed to be incorporated into the local system, adapted to local capacities and priorities, and delivered jointly by local and international team.

G

Design quality & packaging

6

Poorly designed interventions, such as few details in the guidelines, insufficient implementation time.

Using ineffective approaches to deliver interventions.

9

Using interactive and innovative approaches and user-friendly tools to deliver the intervention.

Guidelines were needed as way to enforce behavior change.

2

A

Patient needs & resources

8

Patients' needs of antibiotics affected prescribers' decisions on prescribing antibiotics, as they were often pressured by patients to prescribe antibiotics.

D

External policy & incentives

12

It was difficult to enforce antimicrobial stewardship in countries without national policies or guidelines on antibiotic use.

Weak enforcement of existing regulations on retailers and nation-wide health facilities. As a result, users could access antibiotics from other sources.

10

The interventions were developed in line with national initiatives and priorities.

Availability of nation-wide policies and standardized guidelines.

3

A

Structural characteristics

22

The health facilities where interventions were implemented were lacking infrastructure for implementation, such as insufficient laboratory capacity to provide data on AMR patterns and diagnostic results timely, lack of data management system for audit activities, and lack of in-hospital pharmacies.

The health facilities did not have a sustainable supply of effective antibiotics. Prescribers often had limited access to diagnostic tests.

The health facilities did not have an established governance structure to lead antimicrobial stewardship activities and behavior change interventions.

Researchers faced difficulties in working with different levels of administrative systems in tertiary health facilities.

High turnover of medical staff in health facilities.

8

Creating an environment, in which the participants could carry out the intended behaviors, such as establishing a microbiology laboratory and enhancing the supply of antibiotics.

B

Networks & communications

8

The intervention was developed and implemented by an experienced and well-coordinated team of local and international stakeholders with mutual trust.

Ensuring good communication among implementers, participants, and other stakeholders.

C

Culture

7

Interventions that were developed in a Western context were difficult to implement in other contexts.

Disconnect between physicians and other medical staff, such as laboratory technicians and pharmacists. Physicians often resisted accepting suggestions from nurses or pharmacists.

A rigid hierarchical structure frequently prohibited junior staff from challenging the prescribing decisions made by senior staff.

Tension between doctors and patients during consultations as a barrier to providing adequate antibiotic education for patients.

E1

Leadership engagement

7

Lack of involvement of higher-level leadership and stakeholders in the health facilities.

Lack of support from administrative staff.

21

Receiving support from higher level stakeholders (e.g., officials from Ministry of Health, health authorities, leaders in health facilities) and administrative staff.

E2

Available resources

23

Lack of sustainable financial support for antimicrobial stewardship activities.

Shortage of human resources (e.g., microbiologists, pharmacists, and physicians) to implement interventions.

Target populations were too busy to perform intervention activities.

Lack of technological support to facilitate the implementation of interventions.

5

Availability of technology (e.g., digital tools or electronic medical record systems) for managing data and improve the efficiency of the intervention.

Leveraging locally available but untapped resources for implementing interventions.

E3

Access to knowledge & information

9

Employing training, education, and other promotional strategies helped participants access intervention information and familiarize themselves with intervention activities and content.

4

A

Knowledge & beliefs about the intervention

8

Target populations often lacked awareness of the ongoing behavior change interventions and activities. In some cases, they were concerned about the effectiveness of the intervention or unfamiliar with the intervention content.

7

Participants acknowledged the intervention to be important and useful, and the intervention further promoted their awareness of AMR.

C

Individual stage of change

11

Target populations sometimes were reluctant or even resisted to change their routine practice, because participants were skeptical about the effectiveness of the intervention. In some cases, participants had already established perceptions around “best practices” for treatment.

E

Other personal attributes

6

Prescribers often lacked motivation for changing their prescribing practice. Some commented on concerns with complaints from patients and reduction in salary.

5

B

Engaging

13

Involving a multidisciplinary team of physicians, clinicians, and nurses.

B2

Formally appointed internal implementation leaders

8

A dedicated focal person for coordinating antimicrobial stewardship activities (e.g., performing auditing) and support hospital administration was needed. In many studies, pharmacists often took the role as the focal person.

D

Reflecting & evaluating

5

Lack of standard indicators for evaluating the effectiveness of behavior change interventions.

Lack of systems that continue to collect data for monitoring and evaluating the effectiveness of the interventions.

5

Regular monitoring and evaluation of the program using robust methods helped program managers to identify gaps and areas for improvement.