A behavioural approach to specifying interventions: what insights can be gained for the reporting and implementation of interventions to reduce antibiotic use in hospitals?

Eilidh M Duncan* (Corresponding Author), Esmita Charani, Janet E Clarkson, Jill J Francis, Katie Gillies, Jeremy M Grimshaw, Winfried V Kern, Fabiana Lorencatto, Charis A Marwick, Jo McEwen, Ralph Möhler, Andrew M Morris, Craig R Ramsay, Susan Rogers Van Katwyk, Magdalena Rzewuska, Brita Skodvin, Ingrid Smith, Kathryn N Suh, Peter G Davey

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

16 Citations (Scopus)
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BACKGROUND: Reducing unnecessary antibiotic exposure is a key strategy in reducing the development and selection of antibiotic-resistant bacteria. Hospital antimicrobial stewardship (AMS) interventions are inherently complex, often requiring multiple healthcare professionals to change multiple behaviours at multiple timepoints along the care pathway. Inaction can arise when roles and responsibilities are unclear. A behavioural perspective can offer insights to maximize the chances of successful implementation.

OBJECTIVES: To apply a behavioural framework [the Target Action Context Timing Actors (TACTA) framework] to existing evidence about hospital AMS interventions to specify which key behavioural aspects of interventions are detailed.

METHODS: Randomized controlled trials (RCTs) and interrupted time series (ITS) studies with a focus on reducing unnecessary exposure to antibiotics were identified from the most recent Cochrane review of interventions to improve hospital AMS. The TACTA framework was applied to published intervention reports to assess the extent to which key details were reported about what behaviour should be performed, who is responsible for doing it and when, where, how often and with whom it should be performed.

RESULTS: The included studies (n = 45; 31 RCTs and 14 ITS studies with 49 outcome measures) reported what should be done, where and to whom. However, key details were missing about who should act (45%) and when (22%). Specification of who should act was missing in 79% of 15 interventions to reduce duration of treatment in continuing-care wards.

CONCLUSIONS: The lack of precise specification within AMS interventions limits the generalizability and reproducibility of evidence, hampering efforts to implement AMS interventions in practice.

Original languageEnglish
Pages (from-to)1338–1346
Number of pages9
JournalJournal of Antimicrobial Chemotherapy
Issue number5
Early online date4 Feb 2020
Publication statusPublished - May 2020

Bibliographical note

Funding received from the Research Council of Norway (RCN) through the Joint Programming Initiative on Antimicrobial Resistance (JPIAMR) under the fourth call (2016). Costs included travel costs, running face-to-face meetings and dissemination of results. The Health Services Research Unit is core funded by the Chief Scientist Office of the Scottish Government Health and Social Care Directorates. J.M.G. holds a Canada Research Chair in Health Knowledge Transfer and Uptake. E.C. is funded by the National Institute of Health Research Imperial Biomedical Research Centre and the National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Healthcare Associated Infections and Antimicrobial Resistance at Imperial College London and the Economic and Social Research Council. The funders had no role in study design, data collection and analysis, decision to publish or preparation of the report.


  • antibiotics
  • behaviour


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