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J Antimicrob Chemother. 2020 Feb 4. pii: dkaa001. doi: 10.1093/jac/dkaa001. [Epub ahead of print]

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

Author information

Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland, UK.
NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Faculty of Medicine, Imperial College London, London, UK.
Schools of Dentistry, University of Dundee, Dundee, UK & University of Manchester, Manchester, UK, NHS Education for Scotland, Scotland.
School of Health Sciences, City University of London, London, UK.
Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada and Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
University of Freiburg Medical Center and Faculty of Medicine, Department of Medicine II/Infectious Diseases, Freiburg im Breisgau, Germany.
Centre for Behaviour Change, University College London, London, UK.
Division of Population Health and Genomics, School of Medicine, University of Dundee, Scotland, UK.
Ninewells Hospital, Dundee, UK.
Department of Health Services Research and Nursing Science, School of Public Health, Bielefeld University, Bielefeld, Germany.
Sinai Health System, University Health Network and University of Toronto, Toronto, Canada.
School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada.
Norwegian Advisory Unit for Antibiotic Use in Hospitals, Haukeland University Hospital, Bergen, Norway.
Department of Essential Medicines and Health Products, World Health Organization, Geneva, Switzerland.
Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.



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.


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.


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.


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.


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


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