Exploring barriers to guideline implementation for prescription of surgical antibiotic prophylaxis in Nigeria

Abstract

Background In Nigeria, the prescription of surgical antibiotic prophylaxis for prevention of surgical site infection tends to be driven by local policy rather than by published guidelines (e.g. WHO and Sanford). Objectives To triangulate three datasets and understand key barriers to implementation using a behavioural science framework. Methods Surgeons (N = 94) from three teaching hospitals in Nigeria participated in an online survey and in focus group discussions about barriers to implementation. The theoretical domains framework (TDF) was used to structure question items and interview schedules. A subgroup (N = 20) piloted a gamified decision support app over the course of 6 months and reported barriers at the point of care. Results Knowledge of guidelines and intention to implement them in practice was high. Key barriers to implementation were related to environmental context and resources and concern over potential consequences of implementing recommendations within the Nigerian context applicable for similar settings in low-to-middle-income countries. Conclusions The environmental context and limited resource setting of Nigerian hospitals currently presents a significant barrier to implementation of WHO and Sanford guidelines. Research and data collected from the local context must directly inform the writing of future international guidelines to increase rates of implementation.

Implementation of WHO guidelines for cervical cancer screening, diagnosis and treatment: Knowledge and perceptions of health providers from Argentina

“…28 Another study that examined adherence to mammographic recommendations in the US found that fear of missing cancer diagnoses and malpractice were behind screening practices that differed from age and intervals recommended in guidelines. 29 In their analysis of factors in uencing adherence to antibiotic prescription guidelines, Wood et al 30 pointed out that strategies to increase guidelines utilization should train HPs so they feel empowered and have con dence that they are implementing best practice in line with international standards whilst at the same time maintaining safety of their patients. For Wood et al, 30 this requires awareness raising of the consequences resulting from prescription outside of guideline recommendations, knowledge building of the recommendations set out in guidelines and training provision on how they can be adapted to context.…”

Towards an Antimicrobial Stewardship Program in a Young Tertiary Hospital in Southern Nigeria: A Point Prevalence Survey of Antimicrobial Usage

“…Antimicrobial resistance has been reported to be largely human-driven and prescribers in healthcare facilities are not absolved, more so in developing countries such as Nigeria, where inappropriate prescribing practices by clinicians have been recognized contributors [2] [4] [7]. Inappropriate prescription practices which occur at both in-patient and outpatient settings include the use of wrong dosages, dosing intervals and duration of treatment, use of antibiotics when there is no bacterial infection, and overuse of newer, broad-spectrum antibiotics when either no antibiotic or an older narrow-spectrum drug would be sufficient as well as use of ineffective antimicrobials.…”

“…The high patient to doctor ratio in Nigeria, particularly in public health institutions also is a contributory factor, in that, the clinicians are usually overwhelmed and so unable to take the time to properly counsel patients on appropriate antimicrobial usage [7] [8] [9]. Physicians' attitudes of self-approval, lack of information, apathy, fear of adverse treatment outcomes (including losing patronage and litigation), autonomy of practice and refusal to accept responsibility to prescribe antibiotics appropriately have also been well noted to promote inappropriate prescribing patterns among clinicians [10].…”

“…Also, prescribers are more conscious about the need or otherwise for antimicrobials, antimicrobial guidelines and the need to comply with the latter [11] [12] [13]. ASPs are largely still evolving in Nigeria and not without challenges in terms of management commitment, financial resources, prescriber buy-in and information technology support [7] [12] [14].…”

Gamified Antimicrobial Decision Support App (GADSA) changes antibiotics prescription behaviour in surgeons in Nigeria: A hospital-based pilot study

“…In our pilot, 25% of AB were prescribed without clear indication. There are many reasons for prescribing antibiotics against standardized guidelines (20). There is a lack of oversight, as antimicrobial stewardship programmes in Nigerian hospitals are inadequate (26) and if present, guidelines are being weakly enforced (27).…”