Using Behavior Change Theory to Identify Drivers and Barriers for Antifungal Treatment Decisions: A Case Study in a Large Teaching Hospital in the East of England, UK

Christianne Micallef; Anita H Sung; Maria Gheorghe; Rahael Maladwala; Kate Grady; Christian Kouppas; David A Enoch

doi:10.1007/s40121-023-00796-z

Using Behavior Change Theory to Identify Drivers and Barriers for Antifungal Treatment Decisions: A Case Study in a Large Teaching Hospital in the East of England, UK

Infect Dis Ther. 2023 May;12(5):1393-1414. doi: 10.1007/s40121-023-00796-z. Epub 2023 May 13.

Authors

Christianne Micallef¹, Anita H Sung², Maria Gheorghe³, Rahael Maladwala⁴, Kate Grady⁴, Christian Kouppas⁴, David A Enoch⁵

Affiliations

¹ Pharmacy Department, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK.
² Pfizer Inc., 235 E 42nd St, New York, NY, 10017, USA. anita.sung@pfizer.com.
³ Pfizer SRL, Bucharest, Romania.
⁴ Oliver Wyman, New York, NY, USA.
⁵ Clinical Microbiology and Public Health Laboratory, National Infection Service, UK Health Security Agency, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK.

Abstract

Introduction: Antifungal stewardship (AFS) programs are recognized to contribute to optimizing antifungal prescribing for treatment and prophylaxis. However, only a small number of such programs are implemented. Consequently, evidence on behavioral drivers and barriers of such programs and learnings from existing successful AFS programs is limited. This study aimed to leverage a large AFS program in the UK and derive learnings from it. The objective was to (a) investigate the impact of the AFS program on prescribing habits, (a) use a Theoretical Domains Framework (TDF) based on the COM-B (Capability, Opportunity, and Motivation for Behavior) to qualitatively identify drivers and barriers for antifungal prescribing behaviors across multiple specialties, and (c) semiquantitatively investigate trends in antifungal prescribing habits over the last 5 years.

Methods: Qualitative interviews and a semiquantitative online survey were conducted across hematology, intensive care, respiratory, and solid organ transplant clinicians at Cambridge University Hospital. The discussion guide and survey used were developed to identify drivers of prescribing behavior, based on the TDF.

Results: Responses were received from 21/25 clinicians. Qualitative outcomes demonstrated that the AFS program was effective in supporting optimal antifungal prescribing practices. We found seven TDF domains influencing antifungal prescribing decisions-five drivers and two barriers. The key driver was collective decision-making among the multidisciplinary team (MDT) while key barriers were lack of access to certain therapies and fungal diagnostic capabilities. Furthermore, over the last 5 years and across specialties, we observed an increasing tendency for prescribing to focus on more targeted rather than broad-spectrum antifungals.

Conclusions: Understanding the basis for linked clinicians' prescribing behaviors for identified drivers and barriers may inform interventions on AFS programs and contribute to consistently improving antifungal prescribing. Collective decision-making among the MDT may be leveraged to improve clinicians' antifungal prescribing. These findings may be generalized across specialty care settings.

Keywords: Antifungal stewardship; Antifungal treatment; Behavior change theory; Prescribing habits; Theoretical domains framework.