Objectives This systematic review (SR) reviews the evidence on use of theory in developing and evaluating behaviour change interventions (BCIs) to improve clinicians’ antimicrobial prescribing (AP). Methods The SR protocol was registered with PROSPERO. Eleven databases were searched from inception to October 2018 for peer-reviewed, English-language, primary literature in any healthcare setting and for any medical condition. This included research on changing behavioural intentions (e.g. in simulated scenarios) and research measuring actual AP. All study designs/methodologies were included. Excluded were: grey literature and/or those which did not state a theory. Two reviewers independently extracted and quality assessed the data. The Theory Coding Scheme (TCS) evaluated the extent of the use of theory. Results Searches found 4227 potentially relevant papers after removal of duplicates. Screening of titles/abstracts led to dual assessment of 38 full-text papers. Ten (five quantitative, three qualitative and two mixed-methods) met the inclusion criteria. Studies were conducted in the UK (n = 8), Canada (n = 1) and Sweden (n = 1), most in primary care settings (n = 9), targeting respiratory tract infections (n = 8), and medical doctors (n = 10). The most common theories used were Theory of Planned Behaviour (n = 7), Social Cognitive Theory (n = 5) and Operant Learning Theory (n = 5). The use of theory to inform the design and choice of intervention varied, with no optimal use as recommended in the TCS. Conclusions This SR is the first to investigate theoretically based BCIs around AP. Few studies were identified; most were suboptimal in theory use. There is a need to consider how theory is used and reported and the systematic use of the TCS could help.

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Many countries have developed antimicrobial stewardship programmes with strategies to optimise antimicrobial prescribing. There remains a need for behaviour change interventions at clinician level to promote appropriate prescribing. Theories should be used for developing and evaluating interventions to change human behaviour. Aim / Objectives:The aim of this review was to critically appraise, synthesise and present the available evidence for theoretical approaches in the development and evaluation of behaviour change interventions designed to improve clinicians' antimicrobial prescribing. Design & Methodology: The systematic review protocol was developed and registered with the International Prospective Register of Systematic Reviews (CRD42018098586). Two review authors independently extracted data and assessed study quality. Clinical and methodological heterogeneity limited data synthesis. Results The searches resulted in 4227 relevant articles after duplicates removal. Screening of titles/abstracts led to retrieval and dual assessment of 38 full-text articles. Of those, a total of 10 studies met the inclusion criteria. The majority of studies were carried out in primary care settings (n = 9) targeting upper respiratory tract infections (n = 8). Use of theory varied considerably across studies included. Theory of Planned Behaviour, Social Cognitive Theory and Operant Learning Theory were the most common theories used to inform the design and choice of interventions. Conclusion / Discussion It is feasible to develop and evaluate theoretically based interventions to improve professional practice. The findings of this systematic review will inform understanding of the theoretical basis of behaviour change interventions which contribute to contain AMR rates and prevent the world entering a “post-antibiotic era”.

Introduction: Middle East Respiratory Syndrome (MERS) is a viral respiratory disease caused by a coronavirus variant in the Arabian Peninsula. There is a lack of information regarding awareness and practices of community pharmacists in Qatar for this contagious disease. Aim: To determine the quality of the MERS-related information, recommendations, and counseling practices provided by Qatar’s community pharmacists by using Simulated Client Method (SCM). Materials and Methods: An observational cross-sectional study using a non traditional SCM was conducted in community pharmacies of Qatar from February 2017 to April 2017. A total of 30 community pharmacies were visited twice by two independent simulated clients and data regarding, provision of evidence-based information, recommendations and counseling practices were collected to assess the competency of pharmacists in managing MERS as a primary care problem. Both descriptive and inferential statistical methods were used for data analysis. Results: In present study, majority of pharmacists encountered were male and younger than 45-year-old with 44 (73.3%) each. The average number of pharmacists who did not ask about the patient’s current medical conditions 56 (93.3), medications 58 (97.5%), allergies, and smoking status in both scenarios were not asked by any of the pharmacist. Most of the pharmacists gave an incorrect explanation of MERS 43 (71.7%). The overall quality counselling score for the pharmacists (mean±SD; median (IQR)) was {27.5±4.5; 28.5 (25.3-30.0)}. Quality counselling was significantly related to the type of pharmacy (p=0.0478). Conclusion: Qatar community pharmacist’s MERS related information, recommendations, and counseling practices were below expectations and inconsistent, thus urging the need for continuous professional development.

Introduction A recent systematic review by Talkhan et al demonstrated the need for theoretically based behaviour change interventions in this area. [1] For development of such complex interventions, emphasis should be placed on using theory to systematically identify behavioural determinants of antimicrobial prescribing. Aim To identify and quantify clinicians’ behavioural determinants of antimicrobial prescribing in Qatar. Methods This cross-sectional survey is part of a multi-phase explanatory, sequential mixed methods PhD project in Qatar. Questionnaires were distributed (online and paper based) to all doctors (~4,000) and pharmacists (~400) within Hamad Medical Corporation (HMC, the main healthcare provider). The questionnaire was developed with reference to the Determinants of Implementation Behaviour Questionnaire (a generic questionnaire derived from the 14 theoretical domains of the Theoretical Domains Framework, TDF). [2] Each item was presented as a 5-point Likert scale (scored 5=Strongly agree to 1=Strongly disagree). Personal and practice demographics were also collected for data contextualisation. The draft questionnaire was reviewed for face/content validity by an expert panel of six researchers in Qatar and the UK with experience in the use of the TDF, followed by ‘Think aloud’ testing and piloting. Analysis investigated the behavioural determinants and influential factors through descriptive, principal component analysis (PCA) and inferential analysis. Ethics approval was granted from a UK university and HMC. Results In total, 535 responses were received, 339 (63.4%) from doctors and 196 (36.6%) from pharmacists. Respondents were predominantly male, 346 (64.7%). Just over half (n=285, 53.3%) had ≤ 5 years’ experience as health professionals. PCA showed a three component (C) solution with components incorporating a number of questionnaire items labelled: ‘Guidelines compliance’ (C1 with 8 items), ‘Influences on prescribing’ (C2 with 7 items) and ‘Self-efficacy’ (C3 with 5 items) in prescribing/recommendation activity. A scale score for each respondent was calculated through summation of Likert scores for the relevant questionnaire items within each component. These scales had high internal reliability (Cronbach’s alpha all >0.7) showing consistency in response between component items indicating statistical appropriateness for developing scales. The median score (possible scale range, midpoint) for each scale was C1, 32 (8 to 40, 24), C2, 26 (7 to 35, 21) and C3, 20, (5 to 25, 15). By way of example Table 1 shows levels of agreement for items in C2. This shows lower levels of agreement than C1 scale with the median scale score (26) closer to the midpoint (21) indicating that respondents had less positive views. Inferential analysis using these scale scores and free text analysis is in progress. Conclusion A theoretical basis was used throughout providing insights to behavioural determinants for the development of a theory-based behaviour change intervention. Preliminary results suggest that social influences, staff development and quality monitoring may be useful targets for behaviour change interventions to improve antimicrobial prescribing practice. Limitations include potential social desirability bias and focus on one healthcare organisation/country in the Middle East which may limit generalisability of findings. More in-depth exploration is required to select and test appropriate linked theory-based behaviour change techniques. References 1. Talkhan H, Stewart D, McIntosh T, Ziglam H Palli Valapila, A; Moza Sulaiman H, Diab M, Cunningham S. The use of theory in the development and evalu​ation of behaviour change interventions to improve antimicrobial prescribing: a systematic review. J Antimicrob Chemother. 2020;75(9):2394–2410, Available from https://doi.org/10.1093/jac/dkaa154 [Accessed 12 Oct 2020]. 2. Huijg JM, Gebhardt WA, Dusseldorp E, Verheijden MW, van der Zouwe N, Middelkoop BJ, Crone MR. Measuring determinants of implementation behaviour: psychometric properties of a questionnaire based on the Theoretical Domains Framework. Implement. Sci. 2014;9(1):33.