Hello, and thank you for joining me for the next 10 minutes for some examples to demonstrate how we can understand the role of wider stakeholders to address antimicrobial resistance and implementation of antimicrobial stewardship. And going forward, I will use the acronym AMR for Antimicrobial Resistance. I’m Raheelah Ahmad. I lead the health management programme work at the National Institute for Health Research Health Protection Research Unit at Imperial College. This research unit is dedicated to multidisciplinary research to address AMR. And the work you’ll see today contributes to understanding of innovations in behaviour change, technology, and patient safety from an organisational change and macro-level perspective.
So what do we mean by a macro-level perspective? This is the health sector environment and also wider than that, which may be important to consider when thinking about new interventions, be they technological or policy, and also when evaluating what has or has not worked. You may have seen the outer contexts in the consolidated framework for implementation research in the section on implementation in this course. And that’s also the macro context, the outer context. We’re going to jump straight in now and look at four studies which have looked at this broader question– how can we capture the influence of the wider environment and stakeholders when addressing AMR and implementation of antimicrobial stewardship?
We will run through the methods used and some take-home messages from the findings. All are published studies, and therefore can be read in full. And you may want to replicate some elements of the studies in your own contexts because the approaches here are very context specific or capturing the context, in other words. So study one. How have different countries approached governance and accountability structures and mechanisms for addressing AMR? This study compared England, Germany, and France.
The methods included documentary analysis of literature and policy documents, whereby 79 secondary sources were accessed and analysed. Expert interviews were used to validate the emerging findings. Our approach to analysis was informed by the Smith et al. Framework who seek to explore questions of the how, the who of three main governance processes. And that is setting priorities, monitoring performance against these priorities, and accountability of all actors within the system for their expected contribution. The high-level findings are shown here. And this was a comparison within the country, the wider health system, and how things are being done for the prevention of AMR, and then a comparison between the countries, so across France, England, and Germany.
So we find that England and Germany are quite divergent in their approaches. Using a similar methodology but this time looking at epidemiological data over time, we compared England and Japan and the level of implementation of policies at the national macro level, the organisational meso level, and the micro individual level. And you can see the trajectory over time here between the two countries. We can see a comparison of the different approaches. Here we found a dominance of persuasive approaches in Japan aligned with the cultural learning from industry and the Total Quality Management movement. This is a result of cultural norms, but also as a result of the very short terms of governmental office seen in Japan.
We’re not claiming causation here, of course, but just looking at the context and those wider environmental influences. So we’ve looked at across national comparisons, but we’ve also looked at in-depth at England, where over a 15-year period we have seen a persistent and a large number of policies from the Department of Health, guidance from national level arm’s-length bodies, and from professional bodies, as well as regulatory mechanisms to monitor the improvement in the area of antimicrobial stewardship and infection control. There has been a huge amount of information that’s been available to the public and in the public domain and, of course, to the media.
So study three, we employed a documentary analysis and 130 in-depth qualitative interviews with senior and middle-level managers from 30 English hospitals. By grouping the interventions over time in three major domains– cultural-cognitive, normative and regulative– our findings are contrary to previous research that coercive measures have limited impact. By taking a long-term view of how safety culture was perceived, this study found that the mixed approach, the coercive regulative interventions, had an impact on the way staff prioritised activities to improve infection control, moving from paying attention to what they must do, the regulative, to what they should do, that’s the normative, to what they would always do.
This provides important learning for antimicrobial stewardship initiatives and how to coordinate efforts to a wider safety culture improvement in organisations. I want to leave you with a framework from our most recent study, study four, which looks across seven domains as shown here– political, economic, sociological, technological, ecological, legislative, and industry. This is a framework from strategic management. Our view finds that when addressing AMR at the national level, most analysis have assessed the political domain, but none have looked at all seven of these domains. And we are really not accounting for the technological and industry domains when finding solutions or assessing interventions.
Important facilitators and inhibitors can be identified and leveraged if we take a view of this macro environment across these seven domains. Finally, and in addition to these studies discussed here today, you may also find these two additional resources of interest, particularly when planning new antimicrobial stewardship programmes. Thank you very much for staying with me for this session and look forward to any observations and comments from your own organisation or country context. Thanks again.