Barriers and facilitators of the implementation for the antimicrobial Social Norm Feedback (SNF) intervention...

Although current evidence supports the effectiveness of social norm feedback (SNF) interventions, their sustained integration into primary care remains limited. Drawing on the elements of the antimicrobial SNF intervention strategy identified through the Delphi-based evidence applicability evaluation, this study aims to explore the barriers and facilitators to its implementation in primary care institutions, thereby informing future optimization.

Based on the five domains of the Consolidated Framework for Implementation Research (CFIR), we developed semi-structured interview and focus group discussion guides. Employing purposive sampling, we selected health administrators, hospital managers, physicians, and pharmacists for semi-structured interviews, while patients who had received antimicrobial therapy in primary care institutions participated in focus group discussions. Data collection continued until saturation was achieved, ultimately gathering insights from 36 participants across 5 health administration departments and 7 primary care institutions in 5 locations of Guizhou Province, Southwest China. Textual data were coded and categorized using NVivo 12.

We identified 33 barriers, 38 facilitators, and 1 mixed determinant influencing the persistent implementation of the antimicrobial SNF intervention strategy in primary care institutions. The highest number of factors influencing implementation was found in the inner setting domain. Key barriers included insufficient available resources, insufficient accessibility of knowledge and information, lack of relative priority (referring to the perception that the intervention was less important than competing organizational tasks), organizational culture that prioritizes short-term efficiency, lack of organizational incentives and rewards, inadequate implementation climate, insufficient readiness for implementation, insufficient oversight and leadership engagement, lack of clear goals and feedback, lack of networks and communications, and absence of Pharmacist Council in organizational structure. Improving these factors would promote continuous implementation. Furthermore, facilitators within this domain also included the tension for change (stakeholders' perception that current prescribing practices urgently need improvement), excellent learning climate, excellent compatibility, and organizational structure in newly established large-scale hospitals.

Long-term implementation of the antimicrobial SNF intervention strategy necessitates synergistic effects among intervention characteristics, organizational setting, characteristics of individuals, outer setting, and dynamic implementation process. The study provides critical evidence and references for the sustainable implementation of the antimicrobial SNF intervention strategy and the optimized design of complex interventions in regions with comparable socioeconomic contexts.