VET-ENHANCE Veterinary guidelines to support antimicrobial stewardship: enhancing implementation through behavioural interventions

The use of antimicrobials in veterinary medicine is considered a potential threat for public health. Therefore, antimicrobial stewardship in veterinary medicine is one of the core elements of the Global Action Plan on antimicrobial resistance (AMR). Although there has been a considerable reduction in antimicrobial use (AMU) in veterinary medicine over the last decade in the Netherlands, a further reduction is assumed to be feasible with additional tools, amongst them the development of veterinary guidelines to support veterinarians in applying antimicrobial stewardship principles. Several veterinary treatment guidelines have therefore been published since 2013, however, an implementation strategy to support veterinarians in the adoption and implementation of these guidelines is lacking. From experience in human medicine, it can be learned that compliance to treatment guidelines is generally poor when no additional implementation strategies are in place to support medical professionals in the adoption and implementation of these guidelines. There is a strong indication that adherence to the existing veterinary guidelines can substantially be improved by means of a comprehensive implementation strategy. Different from the doctor-patient relationship in human medicine, the implementation of a guideline for use in production animals needs compliance both from the veterinarian and from the farmer. A crucial aspect is the communication of the recommendations from the guideline by the veterinarian towards the farmer to motivate the farmer to adhere to the advice. This project will identify critical enablers and barriers to the adoption and implementation of veterinary guidelines, and subsequently develop an implementation strategy which will be tested in an intervention trial. In doing so our project aims to promote adoption of and adherence to AMU guidelines by veterinarians and farmers. This will result in a feasible and effective evidence-based implementation strategy for (new) veterinary guidelines that will help to further reduce AMU. The project will exist of 3 consecutive phases. In the first phase, we will use the Theoretical Domains Framework (TDF) for systematically developing an implementation strategy to improve adoption and implementation of veterinary guidelines. In this project we will use the guideline S. suis as a prototypical case. Based on the TDF, we will use a four-step approach in developing an implementation intervention: i) constructing a set of performance indicators to assess current implementation and define implementation targets; ii) identifying enablers and barriers of veterinarians and farmers related to the implementation of the guidelines S. suis based on a TDF based instrument validated to measure determinants of implementation behaviour; iii) selecting theory-based behaviour change techniques and designing a practical and coherent implementation intervention for veterinary guidelines consisting of an infrastructure for dissemination of the intervention and a toolbox containing intervention materials; iv) designing an evaluation plan to assess the effectiveness of the implementation intervention. In the 2nd phase of the project, the developed implementation intervention will be tested in a Stepped-wedge design field trial in 7 peer consultation groups comprising 50 veterinarians in total. In this phase, data regarding performance indicators of implementation, antimicrobial prescribing and use data, animal health parameters and qualitative data derived from participating veterinarians will be collected. In phase 3, the outcomes of the previous phases will be comprehensively reflected upon. This will inform the development of a generic evidence-based implementation strategy (including an infrastructure and a toolbox containing intervention materials) for (new) veterinary guidelines which can easily be used by developers of veterinary guidelines and other stakeholders to improve adherence of veterinarians and farmers to veterinary guidelines. This will be the first comprehensive study that evaluates determinants for adoption and implementation of veterinary guidelines and develops an evidence-based implementation strategy for veterinary guidelines. Ultimately, this will greatly enhance the development of future implementation strategies for veterinary guidelines and thereby contribute to antimicrobial stewardship. In this One Health project, partners with extensive experience in the guideline implementation in human medicine and behavioural scientists work together with veterinarians and the end-users of the product.