ArticlePDF Available

Predictors of physicians’ intentions to use clinical practice guidelines on antimicrobial in tertiary general hospitals of China: a structural equation modeling approach

Authors:

Abstract and Figures

Abstract Background With inappropriate use of antimicrobials becoming a great public health concern globally, the issue of applying clinical practice guidelines (CPGs) to regulate the rational use of antimicrobials has attracted increasing attention. Taking tertiary general hospitals in China for example, this study aimed to identify factors to investigate the comprehensive influencing mechanism for physicians’ intention to use CPGs on antimicrobials. Methods Based on the integration of Theory of Planned Behavior (TPB), Technology Acceptance Model (TAM), and Technology-Organization-Environment framework (TOE), a questionnaire survey was conducted covering potential determinants of affecting physicians’ intentions to use CPGs on antimicrobials at the individual level (attitude, subjective norms and perceived risk), technical level (relative advantage and ease of use), and organizational level (top management support and organizational implementation). Data were collected from 644 physicians in tertiary general hospitals in eastern, central and western China, which were obtained by multi-stage random sampling. The structural equation modeling (SEM) was used to link three-level factors with physicians’ behavioral intentions. Results The majority of the participants (94.57%) showed a positive tendency toward intention to use CPGs on antimicrobials. The reliability and validity analysis showed the questionnaire developed from the theoretical model was acceptable. SEM results revealed physicians’ intentions to use CPGs on antimicrobials was associated with attitude (β = 0.166, p
Content may be subject to copyright.
Dengetal. Antimicrob Resist Infect Control (2021) 10:97
https://doi.org/10.1186/s13756-021-00966-z
RESEARCH
Predictors ofphysicians’ intentions touse
clinical practice guidelines onantimicrobial
intertiary general hospitals ofChina:
astructural equation modeling approach
Qingwen Deng, Zhichao Zeng, Yuhang Zheng, Junhong Lu and Wenbin Liu*
Abstract
Background: With inappropriate use of antimicrobials becoming a great public health concern globally, the issue
of applying clinical practice guidelines (CPGs) to regulate the rational use of antimicrobials has attracted increasing
attention. Taking tertiary general hospitals in China for example, this study aimed to identify factors to investigate the
comprehensive influencing mechanism for physicians’ intention to use CPGs on antimicrobials.
Methods: Based on the integration of Theory of Planned Behavior (TPB), Technology Acceptance Model (TAM), and
Technology-Organization-Environment framework (TOE), a questionnaire survey was conducted covering potential
determinants of affecting physicians’ intentions to use CPGs on antimicrobials at the individual level (attitude, subjec-
tive norms and perceived risk), technical level (relative advantage and ease of use), and organizational level (top man-
agement support and organizational implementation). Data were collected from 644 physicians in tertiary general
hospitals in eastern, central and western China, which were obtained by multi-stage random sampling. The structural
equation modeling (SEM) was used to link three-level factors with physicians’ behavioral intentions.
Results: The majority of the participants (94.57%) showed a positive tendency toward intention to use CPGs on
antimicrobials. The reliability and validity analysis showed the questionnaire developed from the theoretical model
was acceptable. SEM results revealed physicians’ intentions to use CPGs on antimicrobials was associated with attitude
(β = 0.166, p < 0.05), subjective norms (β = 0.244, p < 0.05), perceived risk (β = 0.113, p < 0.05), relative advantage
(β = 0.307, p < 0.01), top management support (β = 0.200, p < 0.05) and organizational implementation (β = 0.176,
p < 0.05). Besides, subjective norms, perceived risk, relative advantage, ease of use, and top management support
showed their mediating effects from large to small on the intentions, which were 0.215, 0.140, 0.103, 0.088, 0.020,
respectively.
Conclusions: This study revealed the significance of multifaceted factors to enhance the intention to use CPGs on
antimicrobials. These findings will not only contribute to the development of targeted intervention strategies on
promoting the use of CPGs on antimicrobials, but also provide insights for future studies about physicians’ adoption
behaviors on certain health services or products.
Keywords: Antimicrobials, Clinical practice guidelines, Structural equation modeling, Utilization, China
© The Author(s) 2021. Open Access This ar ticle is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the
original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or
other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line
to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory
regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this
licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco
mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Open Access
*Correspondence: wenbinliu126@126.com
School of Public Health, Fujian Medical University, Room 108 in the
Building for School of Public Health, No.1 Xuefubei Road, Minhou District,
Fuzhou 350122, China
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 2 of 10
Dengetal. Antimicrob Resist Infect Control (2021) 10:97
Background
Antimicrobials, which have been critically important in
the evolution of medical treatment, effectively reduces
the morbidity and mortality from infections [1]. How-
ever, the spread of inappropriate use of antimicrobials
has driven the emergence of antimicrobial resistance
(AMR), which is a widely acknowledged threat to global
health and sustainable development [2]. It leads to weak-
ened effectiveness and persistent infections [3] that will
greatly undermine our ability to fight infectious disease,
resulting in negative consequences at the individual and
societal levels [4], such as longer hospital stays, higher
medical costs, poor patient outcomes and waste of health
resources. More than 20 billion dollars in the American
health system and over 700,000 deaths worldwide were
linked to AMR in 2016 [5]. e World Bank estimates
that AMR might put 28 million people in an extremely
poor situation by 2050, and loss of the global gross
domestic product caused by AMR would be close to the
2008 global financial crisis [6].
To avoid further deteriorations caused by AMR and
improve outcomes of antimicrobials, many countries
have launched clinical practice guidelines (CPGs) on
antimicrobials, which provide recommendations for phy-
sicians based on the current best evidence. As reported
by the American Institute of Medicine [7], CPGs have
played an important role in standardizing clinical treat-
ment behaviors, improving the quality of medical ser-
vices, and promoting patients’ health. Although clear
principles had been established with significant effec-
tiveness of CPGs well proved, the expansion of regula-
tion implementation was still halted with poor adherence
to regarding guidelines. is situation was outstanding
especially in many developing countries, where antimi-
crobials consumption doubled between 2000 and 2015
[8]. For instance, in China, one of the world’s largest con-
sumers of antimicrobials for human health [9], the inap-
propriate use of antimicrobials is still striking even after
the launch of Guiding Principles for Clinical Application
of Antimicrobials in 2015 [10].
Given the severe situation of AMR worldwide and
guidelines’ contributing role of improving service qual-
ity and patients’ health, the key point of improving the
AMR issue is that the appropriate use of antimicrobials
could be regularized by the use of CPGs on antimicro-
bials [11]. Efforts have been made to understand which
factors could predict physicians’ antimicrobials pre-
scribing using various behavioral theories, such as the
eory of Planned Behavior (TPB), the knowledge-atti-
tude-practice (KAP) model, the Technology Acceptance
Model (TAM), and the Technology-Organization-Envi-
ronment framework (TOE). e focus of these theo-
ries varies from the individual to the technical to the
organizational environment. However, despite a few
studies have considered the influencing factors from
different levels of prescribing behavior [2], most of the
current studies were fragmented and focused on only
one aspect of the determinants. For example, many
studies have investigated health professionals’ beliefs
and practices from the individual level [1216]. And
more importantly, our understanding on physicians’
actual intentions of using CPGs on antimicrobials and
its influencing factors is still limited. As key stakehold-
ers in clinical practice, it’s necessary to understand phy-
sicians’ beliefs and uses of CPGs on antimicrobials and
reasons for using or not using it if we did attempt to
promote the appropriate use of antimicrobials [1, 17].
While to some extent, behavioral intention figures a
proxy role on actual behaviors [18]. If individuals show
a positive or negative intention, we presume that they
would tend to use or not use a specified technology or
other products. erefore, we targeted physicians in
tertiary general hospitals, aimed to establish a model
that integrated from TPB, TAM and TOE for determin-
ing physicians’ intentions to use CPGs on antimicrobi-
als and its influencing factors. e findings can not only
serve as evidence to better AMR control via the pro-
motion of the use of CPGs on antimicrobials, but also
provide a feasible reference for future research on the
influencing factors of physicians’ intention or behaviors
on utilizing certain health services or products.
Methods
Study setting
is study was conducted in tertiary general hospitals
in China. Although the regulation policy for the clinical
application of antimicrobials covers all levels of medical
institutions, for the weakness of the primary medical ser-
vices system in China, the provision of vast medical ser-
vices is heavily dependent on hospitals, especially tertiary
hospitals. In 2019, tertiary hospitals received 1.77 billion
medical visits [19]. As one of the major consumers of
antimicrobials, the irrational use of antimicrobials in ter-
tiary hospitals is quite prominent. us, it’s necessary to
regulate the use of antimicrobials of physicians in tertiary
hospitals for reducing AMR.
Theoretical framework
e theoretical framework (Fig. 1) was adapted from
the integration of TPB, TAM and TOE to illuminate the
determinants of physicians’ intentions to use CPGs on
antimicrobial from three levels, namely individual level
(physicians), technical level (CPGs on antimicrobial), and
organizational level (hospitals).
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 3 of 10
Dengetal. Antimicrob Resist Infect Control (2021) 10:97
Individual‑level factors
Proposed by TPB, behavioral intention is a function of
three factors, including attitude, subjective norms and
perceived behavioral control [20]. Attitude is defined as
a positive or negative evaluation of a particular behavior
[21], many studies showed a strong correlation between
attitude and intention [22, 23]. Subjective norms are
kinds of perceived criteria and social pressure to engage
or not to engage in behavior [24], which may also sig-
nificantly affect physicians’ intentions. Also, perceived
behavioral control reflects the person’s belief that an
action is under his or her control, such as perceived risk.
Risk perception is associated with low intentions.
Technical‑level factors
Proposed by TAM, the relative advantage is a degree to
which new technology or product is more advantageous
than the original or competing ones [25], while ease of
use is a degree to which the potential user expects the
product can perform with ease [26, 27]. Regarding the
intentions to use CPGs, the physicians and managers are
more inclined to adopt the guidelines having better out-
comes and efficiency with no additional effort and time
to learn how to implement.
Organizational‑level factors
TOE suggests top management support “can foster inno-
vation by creating an organizational context that wel-
comes change and is supportive of innovations” [28]. In
hospitals, top management’s involvement in the use of
CPGs on antimicrobials through formal measures (e.g.
funding, training, and system building), can ensure the
accomplishment of intended outcomes to a great extent
[29]. Organizational implementation refers to the whole
implementation process of CPGs on antimicrobials,
including providing relevant information, supervision,
and inspection, corrective feedback, respectively [30, 31].
Measurements
Based on the theoretical model, as well as the literature
review of previous studies, a questionnaire with 30 items
was developed for this study (Additional file 1). ree
items in Part 1 were used to measure the intentions to
use CPGs on antimicrobials of physicians. ere were
21 items in Part 2, covering seven potential factors: atti-
tude, subjective norms, perceived risk, relative advantage,
ease of use, top management support and organizational
implementation. Each item in Part 1&2 corresponding
to the constructs was measured using a five-point Likert
scale, where 1 = Strongly disagree, 2 = Disagree, 3 = Neu-
tral, 4 = Agree, and 5 = Strongly agree. And Part 3 was a
personal information card consisted of 6 items, includ-
ing several basic characteristics of participants like gen-
der, age, education, professional degree, department, and
years in practice.
Sampling
Considering the diverse level of socio-economic devel-
opment in different regions of China, a cross-sectional
survey was conducted using a multistage sampling strat-
egy. Firstly, Fujian, Hubei, Yunnan & Sichuan provinces
were randomly selected respectively on behalf of eastern,
central and western regions of China. Secondly, 4 tertiary
general hospitals were selected from each of the selected
regions. Lastly, in each selected hospital, 16–20 physi-
cians were randomly sampled from major departments
Fig. 1 The theoretical framework
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 4 of 10
Dengetal. Antimicrob Resist Infect Control (2021) 10:97
of internal medicine and surgery, respectively. And 3–5
physicians were randomly sampled from departments of
gynecology and obstetrics, ophthalmology and otorhino-
laryngology, orthopedics, and others, respectively. us,
50–60 physicians from each hospital were invited to par-
ticipate in the survey.
Data collection
A cross-sectional questionnaire survey was performed to
investigate the determinants of physicians’ intentions to
use CPGs on antimicrobials in China. With the support
of sampled hospitals, each round for filling out the ques-
tionnaire was accompanied by trained facilitators. e
purpose of the study and the use of data will be explained
in detail to ensure the participants understand what they
needed to do and how to do it. All responses were anony-
mous, filled out by the participants at their convenience
and returned directly to the researchers.
Data collection started from April 2018 and lasted for
nearly one year. Overall, a total of 676 questionnaires
were returned. After excluding responses that (1) pro-
vided the same response for all items, (2) incomplete
questionnaires, we obtained 644 valid questionnaires
with a valid response rate of 95.27%.
Data analysis
is study used SPSS 21.0 and AMOS 17.1 software pro-
grams as the two main statistical tools to analyze the data.
To analyze the descriptive data and investigated variables
clearly, several steps were followed. Firstly, descriptive
statistics were performed for the analysis of participants’
distribution characteristics. Secondly, we conducted the
assessment of reliability and validity via Cronbach’s α
Coefficient and factor analysis to tell whether the ques-
tionnaire was acceptable. Finally, structural equation
modeling (SEM) was used to analyze the mechanism and
the relationship between the factors via path analysis and
mediating effect test. e path coefficients calculated by
path analysis are equivalent to the standardized regres-
sion coefficients and direct effects. e mediating effects
(indirect effects) and total effects were obtained by medi-
ating effect test. e indirect effects refer to the influence
of one variable on another through a third variable, and
its value was calculated through the Bootstrap method.
If the value does not contain zero in its 95% confidence
interval, the mediating effect is considered significant
[32].
Results
Descriptive characteristics
A total of 644 physicians were included in this study.
Among the participants, 54.50% (n = 351) were males and
45.50% (n = 293) were females. Most participants were in
the age group of under 35years old (55.75%, n = 359),
followed by 35–44years old (34.63%, n = 223). In terms
of educational level, 98.91% (n = 637) reported having a
bachelor’s degree or above. e proportion of the partici-
pants with the professional titles of junior, intermediate,
senior was 38.82%, 38.35%, 22.83%, respectively. Nearly
90% of the participants had less than 15years of prac-
tice experience. And about a third of participants were
from the region of the east, central and west, respectively
(Table1).
Reliability andvalidity
Table2 reports Cronbach’s alpha, composite reliability
(CR), and the average variance extracted (AVE) of all
constructs. e Cronbach’s alpha of 8 constructs and
the whole questionnaire were all greater than the rec-
ommended threshold of 0.7 [33], ranging from 0.810
to 0.885, suggesting internal consistency can be con-
sidered adequate. Besides, all factor loading values of
items were above the acceptability value of 0.5 [34].
Table 1 Demographic characteristics of participants
Variable Category Frequency Percentage (%)
Gender Male 351 54.50
Female 293 45.50
Age < 35 years old 359 55.75
35–44 years old 223 34.63
45 years old 62 9.63
Education Junior college or
below 7 1.09
Bachelor 218 33.85
Master 342 53.11
Doctor 77 11.96
Professional title Junior 250 38.82
Intermediate 247 38.35
Senior 147 22.83
Department Internal medicine 233 36.18
Surgery 188 29.19
Gynecology and
obstetrics 57 8.85
Ophthalmology and
otorhinolaryngology 65 10.09
Orthopedics 44 6.83
Other 57 8.85
Years in practice < 5 years 225 34.94
5–10 years 192 29.81
11–15 years 162 25.16
16–20 years 59 9.16
> 20 years 6 0.93
Region East 217 33.70
Central 210 32.61
West 217 33.70
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 5 of 10
Dengetal. Antimicrob Resist Infect Control (2021) 10:97
Moreover, the CR scores and AVE values of all con-
structs were above the recommended value of 0.7 [35]
and 0.5 [36], respectively, which indicated a good con-
vergent validity.
en, we followed Fornel and Larcker’s (1981) sugges-
tion [34] to calculate the square root of AVE. As shown
in Table3, the square root of AVE (reported in the diago-
nal of correlation matrix) of each construct is higher than
the correlation coefficients of any construct with other
constructs, which means the discriminant validity is
acceptable.
Intentions touse CPGs onantimicrobials andmeasurement
scores ofparticipants
A high intention to use CPGs on antimicrobial in clinical
practice (Mean = 4.12, SD = 0.58) were evident (Table4).
e overwhelming majority (94.57%) scored above neu-
tral, and 33.39% of the intention scores were greater
Table 2 Results of reliability and convergent validity analyses
Construct Item Factor loading Cronbach’s α AVE CR
Attitude ATT1 0.712 0.862 0.632 0.837
ATT2 0.808
ATT3 0.858
Subjective norms SN1 0.776 0.876 0.707 0.879
SN2 0.864
SN3 0.879
Perceived risk PR1 0.699 0.810 0.593 0.813
PR2 0.808
PR3 0.799
Behavioral intention BI1 0.766 0.859 0.610 0.824
BI2 0.810
BI3 0.766
Relative advantage RA1 0.779 0.854 0.666 0.857
RA2 0.835
RA3 0.833
Ease of use EOU1 0.806 0.869 0.692 0.870
EOU2 0.865
EOU3 0.823
Top management support TMS1 0.785 0.837 0.627 0.834
TMS2 0.745
TMS3 0.842
Organizational implementation OI1 0.839 0.885 0.728 0.889
OI2 0.898
OI3 0.821
The whole questionnaire 0.885
Table 3 Results of discriminant validity analysis
Construct PR SN EOU RA TMS AT T OI BI
PR 0.770
SN 0.000 0.841
EOU 0.000 0.000 0.832
RA 0.000 0.000 0.671 0.816
TMS 0.000 0.000 0.588 0.644 0.792
ATT 0.119 0.619 0.198 0.335 0.208 0.795
OI 0.000 0.000 0.468 0.513 0.597 0.166 0.853
BI 0.133 0.347 0.438 0.581 0.571 0.504 0.519 0.781
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 6 of 10
Dengetal. Antimicrob Resist Infect Control (2021) 10:97
than average. e attitudes of the participants showed a
strong tendency in favor of the use of CPGs on antimi-
crobials (M = 4.29, SD = 0.56). eir perceived pressure
(subjective norms) from influential people was relatively
high (Mean = 4.16, SD = 0.59), while their perceived risk
of using CPGs on antimicrobials was found to be low
(Mean = 2.23, SD = 0.85). Most participants, specifically,
87.42% and 84.16% felt positive in relative advantage
(Mean = 3.96, SD = 0.67) and ease of use (Mean = 3.84,
SD = 0.66), respectively. e scores of top management
support (Mean = 4.01, SD = 0.61) and organizational
implementation (Mean = 4.05, SD = 0.60) portrayed the
participants’ appreciation of the organizations’ readiness
to use CPGs on antimicrobials.
Structural equation modeling
A favorable fitness of data into the theoretical frame-
work was found: χ2/df = 3.736 (< 5), GFI = 0.900 (> 0.9),
AGFI = 0.873 (> 0.85), CFI = 0.933 (> 0.9), N FI = 0.911
(> 0.9), IFI = 0.933 (> 0.9), RMSEA = 0.065 (< 0.08),
which demonstrated the research model has fit the data
well.
e final structural model with the standardized esti-
mates among the constructs is presented in Fig.2 and
Table 5. Totally 78.89% of the variance was explained
by the model. Regarding the determinants of physi-
cians’ intentions to use CPGs on antimicrobials, the
model indicated that, at the individual level, an atti-
tude in favor of CPGs on antimicrobials was associated
with higher intentions to use CPGs on antimicrobi-
als (β = 0.166, p < 0.05). Subjective norms predicted
physicians’ intentions to use CPGs on antimicrobials
= 0.244, p < 0.05). Greater perceived obstacles and
risks were linked to lower intentions to use CPGs on
antimicrobials (β =—0.113, p < 0.05). At the technical
Table 4 Measurement scores of the participants
SD Standard deviation
Measurements Mean SD Skewness Median N (%) of scores > 3
Intention 4.12 0.58 0.489 4 609 (94.57)
Attitude 4.29 0.56 0.268 4 625 (97.05)
Subjective norms 4.16 0.59 0.250 4 601 (93.32)
Perceived risk 2.23 0.85 0.700 2 89 (13.82)
Relative advantage 3.96 0.67 0.107 4 563 (87.42)
Ease of use 3.84 0.66 0.229 4 542 (84.16)
top management support 4.01 0.61 0.312 4 587 (91.15)
organizational implementation 4.05 0.60 0.275 4 591 (91.77)
Fig. 2 Determinants of physicians’ intentions to use CPGs on antimicrobials. *p < 0.05; **p < 0.01; ***p < 0.001
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 7 of 10
Dengetal. Antimicrob Resist Infect Control (2021) 10:97
level, better performance in relative advantage was
associated with higher intentions to use CPGs on anti-
microbials (β = 0.307, p < 0.01), while the impact of ease
of use on attitude toward CPGs on antimicrobials was
not significant (β =—0.050, p > 0.05), and the direct
influence of ease of use on the intentions to use CPGs
on antimicrobials was not found. At organizational-
level, top management support (β = 0.200, p < 0.05)
and organizational implementation (β = 0.176, p < 0.05)
were linked to stronger intentions to use CPGs on
antimicrobials.
On the whole, relative advantage figured the strongest
direct and total effects on intention (0.307/0.522), fol-
lowed by subjective norms (0.244/0.347) and top man-
agement support (0.200/0.340). Additionally, significant
mediating effects were also found in the model. Except
that attitude and organizational implementation have
no mediating effect on behavioral intention, other con-
structs mediated the significant effects on the relation-
ship between them. Among them, relative advantage
exerted the strongest indirect effects on intention (0.215),
followed by top management support (0.140), subjec-
tive norms (0.103), ease of use (0.088) and perceived risk
( 0.020).
Discussion
Main ndings
is study revealed that physicians in tertiary general
hospitals of China have high intentions to use CPGs on
antimicrobials, with relatively favorable evaluations and
perceptions on CPGs on antimicrobials. e integrated
model of TPB, TAM and TOE fits well with the data:
intentions to use CPGs on antimicrobials are directly or
indirectly predicted by the attitudes, subjective norms,
perceived risk, relative advantage, ease of use, top man-
agement support and organizational implementation.
Comparison withother studies
Eects ofindividual‑level factors
Consistent with previous studies [3741], attitude and
subjective norms are important factors that have a direct
positive influence on physicians’ intentions to use CPGs
on antimicrobials. In the field of health care, the attitude
and subjective norms of health professionals are often
highlighted as they related to a sense of security in spe-
cific behaviors [42], and are shaped in part by perceived
external pressures on them. Perceived risk has a nega-
tive impact on physicians’ intentions to use CPGs on
antimicrobials. e assumption and perception of vari-
ous potential risks (such as income reduction, failure in
disease control, and patient dissatisfaction) in the imple-
mentation process may hinder the occurrence of behav-
iors. In addition to the direct impacts, both subjective
norms and perceived risk have indirect effects on inten-
tions through attitude. us, we need to pay attention to
the various linking effects of other associated factors if
we want to improve the effect of attitude on intentions.
Eects oftechnical‑level factors
Relative advantage is directly associated with attitude
and intention, which is also in accordance with previous
research [43, 44]. Meanwhile, relative advantage figured
the strongest total, direct and indirect effects on inten-
tion, which revealed that physicians’ intentions to use
Table 5 Results of standardized direct, indirect, and total effects
*p < 0.05; **p < 0.01
Paths Direct eects (path
coecients) Indirect eects Total eects
Attitude Behavioral intention 0.166* 0 0.166*
Subjective norms Attitude 0.619* 0 0.619*
Subjective norms Behavioral intention 0.244* 0.103** 0.347**
Perceived risk Attitude 0.119* 0 0.119*
Perceived risk Behavioral intention 0.113* 0.020* 0.133*
Relative advantage Attitude 0.368** 0 0.368*
Relative advantage Top management support 0.454* 0 0.454*
Relative advantage Behavioral intention 0.307** 0.215* 0.522**
Ease of use Attitude 0.050 0 0.050
Ease of use Top management support 0.283** 0 0.283**
Ease of use Behavioral intention 0.088** 0.088**
Top management support Organizational implementation 0.797* 0 0.797*
Top management support Behavioral intention 0.200* 0.140* 0.340*
Organizational implementation Behavioral intention 0.176* 0 0.176*
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 8 of 10
Dengetal. Antimicrob Resist Infect Control (2021) 10:97
CPGs on antimicrobials can be greatly strengthened if
the CPGs on antimicrobials have advantages in improv-
ing clinical efficacy, promoting practice efficiency and
ensuring patients’ safety.
In contrast to expectations, ease of use was not shown
to have a significant influence on attitude, which is dif-
ferent from the findings of Davis and Venkatesh [45, 46].
e plausible reason may be that the role of ease of use
often has no significant effect at the beginning of imple-
mentation, which is similar to the statement proposed
in a previous study [47] that the impact of ease of use is
limit at an early stage of technology uptake. Another pos-
sibility we also can’t rule out is that the impact of ease of
use on attitude was reduced by relative advantage, which
is also included in the final model demonstrating a great
association with ease of use and significant impacts on
attitude.
Eects oforganizational‑level factors
In terms of hospital level, it is reported that physicians’
intentions and utilization of using CPGs on antimicro-
bials were significantly influenced by top management
support [48]. As influential people in the hospitals,
top managers play important roles in developing the
organizational vision and culture, as well as shaping the
expected behavior and norms of physicians [49]. e
support of hospital top managers for the use of CPGs
on antimicrobials is often reflected in the establish-
ment of a series of systems and mechanisms to assess,
motivate and supervise the realization of correspond-
ing goals, which can not only directly stimulate the use
intentions of physicians, but also have an indirect effect
on the intentions through organizational implementation
[50]. In addition to the institutional design, the overall
application of CPGs on antimicrobials in hospitals also
change intentions and further affect the practical use of
physicians. To some extent, top management support
and organizational implementation act as external social
norms, exerting direct or indirect influences on physi-
cians’ behaviors from the outside to the inside, until they
gradually adjust their behaviors to be consistent with the
organization [51].
Policy implications
Based on the understandings of the influencing mecha-
nism of physicians’ intentions to use CPGs on antimicro-
bials, several intervention strategies can be highlighted
for further improving physicians’ intentions and practical
use of CPGs on antimicrobials.
For hospital managers, the use of CPGs on antimicro-
bials by physicians is promoted more through explicit
means such as regulations. Firstly, providing specific
support (e.g., funding, personnel, information, system)
is one of the effective measures to promote physicians’
intentions to use CPGs on antimicrobials. Secondly, the
establishment of feedback and expert panel is indispen-
sable to timely solve various issues of the implementation
of CPGs on antimicrobials. irdly, education and train-
ing are essential for increasing the knowledge of CPGs on
antimicrobials (including the perceptions of usefulness,
ease of use, and so on), as well as to help physicians foster
positive attitudes toward CPGs on antimicrobials and its
use, which can be adopted as long-term strategies [2].
Hospital managers can also advance the use of CPGs on
antimicrobials by physicians in an implicit approach, that
is, by leveraging subjective norms to increase physicians’
intentions to use CPGs on antimicrobials. Specifically,
this means mobilizing influential people for physicians
(generally referred to department directors, authoritative
experts, etc.) to adapt physicians’ compliance with CPGs
on antimicrobials, which is an internalized process.
Strengths andlimitations
To the best of our knowledge, there were very few
national surveys to investigate the related behaviors of
CPGs on antimicrobials among physicians, particularly
in developing countries. is study examined the mech-
anism of physicians’ intentions to use CPGs on antimi-
crobials based on the integration of TPB, TAM and TOE,
which allowed us to systematically consider the factors
associated with the intentions to use CPGs on antimicro-
bials from three levels, namely individual, technical and
organizational determinants.
ere are also some limitations to this study. Firstly, all
the data were obtained by self-reported, we cannot rule
out the social desirability bias [52] that some physicians
may be unwilling to voice negative assessments about
themselves and the hospitals. Secondly, limited to time
and fund, we focus the factors at the individual, techni-
cal, and organizational-level in this study, and the influ-
ence of external environmental factors will be explored
in future research. irdly, considering the limitation of
a cross-sectional study in causality interpretations, future
research may involve sample at different point of time to
form a panel data, which will be more robust in capturing
the influencing factors.
Conclusions
e present study investigated the determinants of the
physicians’ intentions to the utilization of CPGs on anti-
microbials. SEM approach was used to verify the proposed
conceptual research framework. e findings of this study
revealed the significance of multifaceted factors to enhance
the intention to use CPGs on antimicrobials, including atti-
tude, subjective norms, perceived risk, relative advantage,
ease of use, top management support, and organizational
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 9 of 10
Dengetal. Antimicrob Resist Infect Control (2021) 10:97
implementation. ese findings will not only benefit tai-
loring future interventions for expanding the utilization of
CPGs on antimicrobials, but also provide clues for future
research about physicians’ adoption behaviors on certain
health services or products.
Abbreviations
AMR: Antimicrobial resistance; CPGs: Clinical practice guidelines; SEM: Struc-
tural equation modeling.
Supplementary information
The online version contains supplementary material available at https:// doi.
org/ 10. 1186/ s13756- 021- 00966-z.
Additional le1. Questionnaire. The questionnaire represents the data
collection instrument that was developed for this study, hasn’t previously
been published elsewhere.
Additional le2. STROBE_checklist_cross-sectional. The checklist rep-
resents the details of the manuscript, which reports the information that
meets the criteria of STROBE guidelines.
Acknowledgements
We are thankful to all coordinators and physicians for their participation in this
study.
Authors’ contributions
LW designed and conducted the project, contributed to grasp the subject
and revised the manuscript. ZZ, ZY and LJ performed the data curation and
data analysis. DQ carried out the data analysis and drafted the manuscript.
LW and DQ developed the questionnaire. All authors read and approved the
manuscript before submission.
Funding
This research was supported by National Natural Science Foundation of China
(Grant Number: 71704026) and the Soft Science Project of Fujian Provincial
Department of Science and Technology (Grant Number: 2017R0044). No
funders had a role in study design, data collection, data analysis, or in writing
the manuscript.
Availability of data and materials
The datasets generated during and/or analyzed during the current study are
available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
Ethics approval was obtained from the medical ethics committee, Fujian
Medical University, China. Written informed consent was obtained from all
study participants.
Consent to publish
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Received: 2 November 2020 Accepted: 3 June 2021
References
1. Bakhit M, Del MC, Gibson E, Hoffmann T. Exploring patients’ understand-
ing of antibiotic resistance and how this may influence attitudes towards
antibiotic use for acute respiratory infections: a qualitative study in
Australian general practice. BMJ Open. 2019;9(3):e026735.
2. Liu C, Liu C, Wang D, Zhang X. Intrinsic and external determinants of
antibiotic prescribing: a multi-level path analysis of primary care prescrip-
tions in Hubei China. Antimicrob Resist Infect Control. 2019;8:132.
3. Liu C, Liu C, Wang D, Deng Z, Tang Y, Zhang X. Determinants of antibiotic
prescribing behaviors of primary care physicians in Hubei of China: a
structural equation model based on the theory of planned behavior.
Antimicrob Resist Infect Control. 2019;8:23.
4. Barker AK, Brown K, Ahsan M, Sengupta S, Safdar N. What drives inap-
propriate antibiotic dispensing? A mixed-methods study of pharmacy
employee perspectives in Haryana, India. BMJ Open. 2017;7(3):e013190.
5. O’Neill J. Tackling Drug-Resistant Infections Globally: Final Report and
Recommendations. HM Government and the Wellcome Trust, London;
2016.
6. World Bank Group. Drug resistant infections: a threat to our economic
future. 2017. http:// docum ents. world bank. org/ curat ed/ en/ 32331 14933
96993 758/ pdf/ 114679- REVIS ED- v2- Drug- Resis tant- Infec tions- Final-
Report. pdf. Accessed 18 August 2017.
7. Institute of Medicine (US) Committee on Standards for Developing
Trustworthy Clinical Practice Guidelines. Clinical practice guidelines we
can trust. Washington: National Academic Press; 2011.
8. World Health Organization. Antimicrobial resistance and primary health
care: brief. No. WHO/HIS/SDS/2018.57. 2018.
9. Qiao M, Ying GG, Singer AC, Zhu YG. Review of antibiotic resistance in
China and its environment. Environ Int. 2018;110:160–72.
10. Sun Q, Dyar OJ, Zhao L, Tomson G, Nilsson LE, Grape M, Song Y, Yan L,
Lundborg CS. Overuse of antibiotics for the common cold–attitudes and
behaviors among doctors in rural areas of Shandong Province. China
BMC Pharmacol Toxicol. 2015;16:6.
11. Rusic D, Bozic J, Bukic J, et al. Evaluation of accordance of antibiotics
package size with recommended treatment duration of guidelines for
sore throat and urinary tract infections. Antimicrob Resist Infect Control.
2019;8:30.
12. Panagakou SG, Spyridis Ν, Papaevangelou V, Theodoridou KM, Goutziana
GP, Theodoridou MN, Syrogiannopoulos GA, Hadjichristodoulou CS.
Antibiotic use for upper respiratory tract infections in children: a cross-
sectional survey of knowledge, attitudes, and practices (KAP) of parents
in Greece. BMC Pediatr. 2011;11:60.
13. Huang Y, Gu J, Zhang M, Ren Z, Yang W, Chen Y, Fu Y, Cals JW, Zhang F.
Knowledge, attitude and practice of antibiotics: a questionnaire study
among 2500 Chinese students. BMC Med Educ. 2013;13:163.
14. Salsgiver E, Bernstein D, Simon MS, Eiras DP, Greendyke W, Kubin CJ,
Mehta M, Nelson B, Loo A, Ramos LZ, Jia H, Saiman L, Furuya EY, Calfee
DP. Knowledge, attitudes, and practices regarding antimicrobial use and
stewardship among prescribers at acute-care hospitals. Infect Control
Hosp Epidemiol. 2018;39(3):316–22.
15. Liu C, Liu C, Wang D, Zhang X. Knowledge, attitudes and intentions to
prescribe antibiotics: a structural equation modeling study of pri-
mary care institutions in Hubei, China. Int J Environ Res Public Health.
2019;16(13):2385.
16. Firouzabadi D, Mahmoudi L. Knowledge, attitude, and practice of health
care workers towards antibiotic resistance and antimicrobial stewardship
programmes: a cross-sectional study. J Eval Clin Pract. 2020;26(1):190–6.
17. Rodrigues AT, Roque F, Falcão A, Figueiras A, Herdeiro M. Understanding
physician antibiotic prescribing behaviour: a systematic review of qualita-
tive studies. Int J Antimicrob Agents. 2013;41(3):203–12.
18. Choi J, Lee A, Ok C. The effects of consumers’ perceived risk and benefit
on attitude and behavioral intention: a study of street food. J Travel Tour
Mark. 2013;30:222–37.
19. National Bureau of Statistics of China. National data. National Bureau of
Statistics of China; 2019. http:// data. stats. gov. cn/.
20. Ajzen I. The theory of planned behavior. Organ Behav Hum Decis Process.
1991;50:179–211.
21. Ajzen I, Fishbein M. A bayesian analysis of attribution processes. Psychol
Bull. 1975;82:261–77.
22. Davis FD. Perceived usefulness, perceived ease of use, and user accept-
ance of information technology. MIS Q. 1989;13:319–40.
23. Liu CF, Tsai YC, Jang FL. Patients’ acceptance towards a web-based per-
sonal health record system: an empirical study in Taiwan. Int J Environ Res
Public Health. 2013;10(10):5191–208.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 10 of 10
Dengetal. Antimicrob Resist Infect Control (2021) 10:97
fast, convenient online submission
thorough peer review by experienced researchers in your field
rapid publication on acceptance
support for research data, including large and complex data types
gold Open Access which fosters wider collaboration and increased citations
maximum visibility for your research: over 100M website views per year
At BMC, research is always in progress.
Learn more biomedcentral.com/submissions
Ready to submit your research
Ready to submit your research
? Choose BMC and benefit from:
? Choose BMC and benefit from:
24. Chung A, Rimal RN. Social norms: a review. Rev Comm Res. 2016;4:1–28.
25. Low C, Chen Y, Wu M. Understanding the determinants of cloud comput-
ing adoption. Ind Manage Data Syst. 2011;111:1006–23.
26. Venkatesh V, Davis FD. A theoretical extension of the technology accept-
ance model: four longitudinal field studies. Manage Sci. 2000;46:186–204.
27. Handayani PW, Hidayanto AN, Pinem AA, Hapsari IC, Sandhyaduhita PI,
Budi I. Acceptance model of a hospital information system. Int J Med
Inform. 2017;99:11–28.
28. Baker J. The technology–organization–environment framework Informa-
tion systems theory. New York: Springer; 2012.
29. Soliman KS, Mosbeh R. An exploratory analysis of factors affecting users’
adoption of corporate intranet. Manage Res News. 2008;31:375–85.
30. Helfrich CD, Li YF, Sharp ND, Sales AE. Organizational readiness to change
assessment (ORCA): development of an instrument based on the
Promoting Action on Research in Health Services (PARIHS) framework.
Implement Sci. 2009;4:1–13.
31. Mccormack B, Mccarthy G, Wright J, Slater PL, Coffey A. Development and
testing of the Context Assessment Index (CAI). Worldviews Evid Based
Nurs. 2009;6:27–35.
32. Preacher KJ, Hayes AF. Asymptotic and resampling strategies for assessing
and comparing indirect effects in multiple mediator models. Behav Res
Methods. 2008;40(3):879–91.
33. Nunnally JC. Psychometric theory. 2nd ed. New York: McGraw-Hill; 1978.
34. Fornell C, Larcker DF. Evaluating structural equation models with unob-
servable variables and measurement error. J Mark Res. 1981;18:39–50.
35. Gefen D, Straub DW, Boudreau MC. Structural equation modeling and
regression: guidelines for research practice. Commun Assoc Inf Syst.
1978;4:1–70.
36. Bagozzi RP, Yi Y. On the evaluation of structure equation models. J Acad
Mark Sci. 1998;16:74–94.
37. Azjen I. Understanding attitudes and predicting social behavior. Engle-
wood Cliffs; 1980.
38. Taylor S, Todd PA. Understanding information technology usage: a test of
competing models. Inf Syst Res. 1995;6:144–76.
39. Moon JW, Kim YG. Extending the TAM for a world-wide-web context.
Inform Manage. 2001;38:217–30.
40. Heijden H. Factors influencing the usage of websites: the case of a
generic portal in The Netherlands. Inform Manage. 2003;40:541–9.
41. Ahmed RR, Vveinhardt J, Streimikiene D, Awais M. Mediating and market-
ing factors influence the prescription behavior of physicians: an empirical
investigation. Amfiteatru Econ. 2016;18:153–67.
42. Huang HT, Tsai CH, Wang CF. A model for promoting occupational safety
and health in Taiwan’s hospitals: an integrative approach. Int J Environ Res
Public Health. 2019;16(5):882.
43. Wu JH, Wang SC, Lin LM. Mobile computing acceptance factors in the
healthcare industry: a structural equation model. Int J Med Inform.
2007;76(1):66–77.
44. Zhou J. Let us meet online! examining the factors influencing older Chi-
nese’s social networking site use. J Cross Cult Gerontol. 2019;34(1):35–49.
45. Davis FD, Venkatesh V. A critical assessment of potential measurement
biases in the technology acceptance model: three experiments. Int J
Hum Comput Stud. 1996;45:19–45.
46. Venkatesh V, Davis FD. A model of the antecedents of perceived ease of
use: development and test. Decision Sci. 1996;27:451–81.
47. Venkatesh V, Bala H. Technology acceptance model 3 and a research
agenda on interventions. Decision Sci. 2008;39:273–315.
48. Deng Q, Liu W. Utilization of clinical practice guideline on antimicrobial
in China: an exploratory survey on multilevel determinants. BMC Health
Serv Res. 2020;20(1):282.
49. Grojean MW, Resick CJ, Dickson MW, Smith DB. Leaders, values, and
organizational climate: examining leadership strategies for estab-
lishing an organizational climate regarding ethics. J Bus Ethics.
2004;55(3):223–41.
50. Qureshi QA, Shah B, Ullah N, et al. The impact of top management
support and e-health policies on the success of e-health practices in
developing countries. Scholarly J Med. 2013;3(3):27–30.
51. Hsia TL, Chiang AJ, Wu JH, et al. What drives E-Health usage? Integrated
institutional forces and top management perspectives. Comput Hum
Behav. 2019;97:260–70.
52. Hasegawa K, Shinohara C, Broadbent JP. The effects of ‘social expec-
tation’ on the development of civil society in Japan. J Civil Society.
2007;3:179–203.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in pub-
lished maps and institutional affiliations.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
1.
2.
3.
4.
5.
6.
Terms and Conditions
Springer Nature journal content, brought to you courtesy of Springer Nature Customer Service Center GmbH (“Springer Nature”).
Springer Nature supports a reasonable amount of sharing of research papers by authors, subscribers and authorised users (“Users”), for small-
scale personal, non-commercial use provided that all copyright, trade and service marks and other proprietary notices are maintained. By
accessing, sharing, receiving or otherwise using the Springer Nature journal content you agree to these terms of use (“Terms”). For these
purposes, Springer Nature considers academic use (by researchers and students) to be non-commercial.
These Terms are supplementary and will apply in addition to any applicable website terms and conditions, a relevant site licence or a personal
subscription. These Terms will prevail over any conflict or ambiguity with regards to the relevant terms, a site licence or a personal subscription
(to the extent of the conflict or ambiguity only). For Creative Commons-licensed articles, the terms of the Creative Commons license used will
apply.
We collect and use personal data to provide access to the Springer Nature journal content. We may also use these personal data internally within
ResearchGate and Springer Nature and as agreed share it, in an anonymised way, for purposes of tracking, analysis and reporting. We will not
otherwise disclose your personal data outside the ResearchGate or the Springer Nature group of companies unless we have your permission as
detailed in the Privacy Policy.
While Users may use the Springer Nature journal content for small scale, personal non-commercial use, it is important to note that Users may
not:
use such content for the purpose of providing other users with access on a regular or large scale basis or as a means to circumvent access
control;
use such content where to do so would be considered a criminal or statutory offence in any jurisdiction, or gives rise to civil liability, or is
otherwise unlawful;
falsely or misleadingly imply or suggest endorsement, approval , sponsorship, or association unless explicitly agreed to by Springer Nature in
writing;
use bots or other automated methods to access the content or redirect messages
override any security feature or exclusionary protocol; or
share the content in order to create substitute for Springer Nature products or services or a systematic database of Springer Nature journal
content.
In line with the restriction against commercial use, Springer Nature does not permit the creation of a product or service that creates revenue,
royalties, rent or income from our content or its inclusion as part of a paid for service or for other commercial gain. Springer Nature journal
content cannot be used for inter-library loans and librarians may not upload Springer Nature journal content on a large scale into their, or any
other, institutional repository.
These terms of use are reviewed regularly and may be amended at any time. Springer Nature is not obligated to publish any information or
content on this website and may remove it or features or functionality at our sole discretion, at any time with or without notice. Springer Nature
may revoke this licence to you at any time and remove access to any copies of the Springer Nature journal content which have been saved.
To the fullest extent permitted by law, Springer Nature makes no warranties, representations or guarantees to Users, either express or implied
with respect to the Springer nature journal content and all parties disclaim and waive any implied warranties or warranties imposed by law,
including merchantability or fitness for any particular purpose.
Please note that these rights do not automatically extend to content, data or other material published by Springer Nature that may be licensed
from third parties.
If you would like to use or distribute our Springer Nature journal content to a wider audience or on a regular basis or in any other manner not
expressly permitted by these Terms, please contact Springer Nature at
onlineservice@springernature.com
... It should be noted that the TAM is limited by leaving out some importance variables, such as perceived security, which has been reported a major concern for both nurses and users [21]. Perceived security is defined as "the degree to which one believes that security is guaranteed when using new technologies", and was regarded as a critical construct that explains users' attitude towards newly developed technological products [22,23]. Therefore, we modified the TAM by including perceived security as an explaining variable linking to attitude. ...
... Previous studies consistently found significant relationship between perceived security and attitude towards new tech products [22,23,30]. A possible explanation is that when people perceive potential risks associated with new technology or technology based services, their trust in the service compromised, which in turn leads to negative attitudes toward the service [30]. ...
... Different studies involving the association between perceived ease of use and attitude had inconsistent results. Some studies suggested that perceived ease of use was directly associated with attitude [31,37], whereas consistent with our findings, two studies did not find significant relationship between perceived ease of use and attitude towards clinical practice guidelines on antimicrobial [22] and electronic health care records [30]. This insignificant result may be because the participants in our study were relatively young and highly educated, and therefore, they might be very proficient in technology use, which does not necessarily relate to positive attitude directly [30,37]. ...
Article
Full-text available
Background In China, Internet-Based Sharing Nursing Service (IBSNS) is a new mode of nursing service delivery that has been in practice for over five years, which enables nurses to provide care at clients’ home. However, the acceptance and associated factors of IBSNS among caregivers of elderly with chronic diseases who are the major clients of the service were unclear. Aim To explore the acceptance of IBSNS and its associated factors among Chinese caregivers of elderly patient with chronic diseases based on the modified Technology Acceptance Model (mTAM). Methods A cross-sectional study was conducted from February 2023 to March 2023. Caregivers of hospitalized elderly with chronic diseases were recruited using convenience sampling method from three hospitals in Beijing, China. Data were obtained from self-reports of participants. Structural equation modeling was used to analyze data. Results A total of 65.1% of the caregivers had neutral to weakly positive behavioral intention of IBSNS use. The mTAM model was supported with good model fit. Perceived ease of use was positively associated with perceived usefulness. Both perceived usefulness and perceived security were positively associated with attitude, consequently, attitude was associated with behavioral intention. Conclusions Improving the ease of use, security, and usefulness may be helpful to increase the positive attitude towards IBSNS and behavioral intention of using IBSNS, which provides valuable insights that can help healthcare providers improve the integration of technology in patient care, ultimately leading to better health outcomes and more efficient healthcare systems.
... And under the guidance of TPB, Fatemeh et al.found that social norm feedback interventions based on subjective norms improved antimicrobials prescribing behavior that lasted at least three months after the intervention (20). Furthermore, by integrating TPB and other related theoretical models, Deng et al. found that subjective norms had signi cant direct and indirect effects on intention to use CPGs on antimicrobials, and the impact of subjective norm on individual attitude was also con rmed (21). It is worth noting that although recently social norms have received special attention as determinants of antimicrobials prescribing behaviors or regarding CPGs compliance, most studies have only proposed a single level of social norms: either individual normative beliefs, or acceptance pressure at the social normative level (22)(23)(24)(25)(26). ...
... TNSB believes that organizational criterion is one of the most important factors in uencing the behavior intention of organization members, which subsequently in uence the nal practice (14). Meanwhile, the indirect effect of organizational criterion on behavior intention with attitude as a key intermediate factor was also con rmed in previous studies (21,24). ...
Preprint
Full-text available
Background With the improper use of antimicrobials becoming a major public health concern globally, poor compliance of clinical practice guidelines(CPGs) on antimicrobials is still prominent, especially in less developed regions. Although social norms have received increasing attention as the determinants of physicians’ CPGs use, most studies set forth only a single level of social norms. Therefore, this study aims to investigate the impact of multifaceted social norms on physician’ use of CPGs on antimicrobials, and further reveal the temporal effects of social norms. Methods Based on integration of Theory of Planned Behavior and Theory of Normative Social Behavior, a questionnaire survey was conducted covering social norms at individual level (subjective norms), organizational level (organization criterion) and social level (social identity), as well as other potential factors (attitudes, behavioral intention, etc) for the use of CPGs on antimicrobials. Data were collected by multi-stage random sampling from 502 physicians in secondary and tertiary general hospitals in central-western China. Structural equation model (SEM) was used to link the three-level factors with physician's behavior. And with reflected by the moderating effects of professional titles in this study, the temporal effects of social norms were examined by multi-group SEM. Results Nearly 70% of the participants had a good practice of using CPGs on antimicrobials. Reliability and validity analysis shows that the questionnaire developed from the theoretical model is acceptable. Subjective norms, organization criterion and social identity were linked to higher behavioral intentions(β = 0.212, p < 0.01; β = 0.254, P < 0.01; β = 0.212, P < 0.01). The direct effect of behavior intentions on physicians' practice was 0.822, and the indirect effects of subjective norms, organizational criterion and social identity on practice were 0.308, 0.236 and 0.235. The effects of organization criterion and social identity on behavior were moderated by the professional title, and regarding effects would be weakened with the rise of professional title. Conclusion This study reveals the importance of multifaceted social norms in enhancing physicians’ use of CPGs on antimicrobials and the moderating effects of professional titles on the role of social norms at organizational level (organizational criterion) and social level (social identity).
... Additionally, information technology infrastructure, system reliability, and government policies are significantly related to the adoption of mobile healthcare by hospitals, but with a negative correlation. There are also studies using the TOE framework to conduct a questionnaire survey on the potential factors affecting doctors' willingness to use clinical practice guidelines for antimicrobial drugs (10). Therefore, the TOE framework, as a commonly used analytical framework, can be used to assess the factors affecting organizational performance. ...
Article
Full-text available
Objective By studying the Technology-Organization-Environment Framework (TOE), this research explores the impact of various indicators in technology, organization, and environment on the performance of family doctor services during major public health emergencies. It aims to identify the driving paths to improve performance. Methods A stratified sampling of 34 community health service centers in Shanghai was conducted, using the comprehensive performance score of family doctors as the outcome variable. The Average Internet Medical Service Person-times and the Information Technology Expenditure per Thousand Population were considered as technology-related variables. The Fiscal Allocation per Thousand Population (/1,000), the Family Doctor Team Members per Thousand Population, and the Medical Social Workers and Volunteers per Thousand Population were identified as organization-related variables. The Proportion of Older Adult Population, Fiscal Allocation per Thousand Population, and the number of patient self-education organizations per thousand population were taken as environment-related variables. Fuzzy-set Qualitative Comparative Analysis (fsQCA) was employed to conduct necessity analysis, truth table analysis, and configurational analysis of antecedent conditions, with robustness tests performed by adjusting consistency thresholds and case frequencies. Results The study found that the performance of family doctor services was influenced by multiple factors, with no single decisive factor. In overall communities, five configurations, including per capita fiscal allocation and community participation, affected performance, explaining 4.2% of the variance. In central urban areas, information technology expenditure and the Proportion of Older Adult Population were core conditions, influencing 27.5% of performance paths. In non-central urban areas, core conditions such as financial support and IT covered 53.9% of data cases. The fsQCA results, which were robustly tested, begin to provide a strong basis for resource allocation and policy formulation. Conclusion This study begins to fill the gap in research on family doctor service performance during major public health emergencies, exploring the synergistic effects and causal asymmetry among multiple indicators such as technology, organization, and environment from a holistic, or configurational, perspective.
... 本研究的结构方程模型结果显示:医生策略性 行为的意向对实际行为具有显著影响,路径系数为0.606,表明行为意向在行为预测中起关键作用,与既往研究[16][17] 结果一致。这一结果强调了行为意向的 体系[23] ,营造合法合规开展医疗服务的环境,引导医生正确认识 DRG 支付制度和诊疗行为规范,以有效 防止策略性行为的发生。着眼于控制信念视角,可 以 从 调 整 本 地 化 DRG 分 组 方 案 ...
Article
Full-text available
Objectives: Reforming medical insurance payment methods is a key part of deepening the healthcare system reform. Understanding the influencing factors and underlying mechanisms of physicians' strategic behaviors under the diagnosis-related groups (DRG) payment system is crucial for reducing medical resource waste and improving the efficiency of health insurance fund utilization. Methods: Based on the Theory of Planned Behavior, this study used grounded theory to construct a questionnaire encompassing belief, behavioral attitude, subjective norm, perceived behavioral control, behavioral intention, and behavior measurement items. Structural equation modeling was then used for empirical analysis. Results: Physicians' behavioral intention had the most significant impact on their strategic behavior (β=0.606, P<0.001). Physician's attitude toward strategic behavior (β=-0.159, P<0.01), subjective norm (β=-0.093, P<0.05), and perceived behavioral control (β=-0.120, P<0.05) were major influencing factors of behavioral intention. Physicians' behavioral beliefs, normative beliefs, and control beliefs were significantly correlated with behavioral attitude (β=0.554, P<0.001), subjective norm (β=0.383, P<0.001), and perceived behavioral control (β=0.274, P<0.001), respectively. Conclusions: Behavioral intention is the primary predictor driving physicians to engage in strategic behavior. Attitudes toward the behavior, subjective norms, and perceived behavioral control all significantly affect physicians' behavioral intentions.
... RA describes the extent to which an individual recognizes technology components as more beneficial or advantageous compared to existing alternatives (Rawashdeh et al., 2023;Song and Jo, 2023). RA measures the extent to which new technologies are considered superior to alternative existing tools (Deng et al., 2021). RA also refers to an innovation that is considered superior to the previous idea it replaces, which significantly affects user acceptance and user readiness to embrace innovative technology (Chan et al., 2019;Srivastava et al., 2023). ...
Article
The adoption of cloud accounting technology among micro, small, and medium enterprises (MSMEs) is becoming increasingly vital for enhancing corporate efficiency and sustainability. However, the adoption rate requires enhancement due to several obstacles, including insufficient digital literacy (DLC) and technological complexity (CX). This study aims to identify the factors influencing the adoption of cloud accounting in MSMEs using TAM framework. This research encompassed 307 participants from MSMEs in Indonesia, with data gathered via surveys and analyzed with the Structural Equation Model—Partial Least Squares (SEM-PLS). DLC and compatibility (CO) substantially affect the perceived ease of use (PE) and usefulness (PU) of cloud accounting technology. Meanwhile, relative advantage (RA) positively impacts PE but does not significantly influence PU. CX greatly influenced users’ intention (INT) to embrace cloud accounting. These findings highlights the crucial role of TAM and indicate that enhancing DLC and CO alongside current business practices is essential to promoting technology adoption. This study provides practical recommendations for policymakers and technology providers to improve the use of digital technologies among MSMEs.
... 8 Top-down support of AS programs and implementation of AS activities contributes to clinician uptake of prescribing guidelines. 9 Public announcement of intentionsin this case, to use antimicrobials more judiciouslyis thought to create external motivation to actually achieve that behavior. 10,11 A quarter of schools reported no activities related to core principle 4, evaluate antimicrobial drug use practices, and a third of schools did not intend to review appropriateness of prescribing for priority conditions. ...
Article
Full-text available
OBJECTIVE To understand antimicrobial stewardship (AS) and infection prevention and control (IPC) activities in veterinary schools. METHODS An online survey was completed by representatives from American Association of Veterinary Medical Colleges–accredited veterinary schools in the US and Caribbean prior to attending the Inaugural Small Animal Antimicrobial Stewardship Workshop for US Veterinary Schools. Responses were examined to identify patterns among AS and IPC activities and adherence to the AVMA core principles. RESULTS Half (12 of 24) of the surveyed schools had an AS committee and most (79% [19 of 24]) had an IPC committee. Lack of dedicated staff time was a common barrier to AS (88% [21 of 24]) and IPC (75% [18 of 24]) reported by schools both with and without AS and IPC committees. Eleven of 24 schools (46%) reported performing at least 1 activity focused on each of the AVMA’s 5 core principles of AS. Although 79% (19 of 24) of schools incorporate AS into preclinical curricula, training of clinical faculty (17% [4 of 24]), veterinary technicians and support staff (21% [5 of 24]), and house officers (42% [10 of 24]) is less common, despite these individuals engaging in teaching clinical-year veterinary students. CONCLUSIONS Veterinary schools varied in established AS education and AS and IPC practices, though financial and human resources were a common barrier. CLINICAL RELEVANCE A collaborative and cohesive approach to AS and IPC among schools to create sustainable frameworks for practice improvement will help combat the global threat of antimicrobial resistance. This is a critical action for settings where future veterinarians are trained.
... Furthermore, this effect manifested consistently in leading hospitals and subordinate hospitals. It appeared that when clinicians recognized the value of adopting hepatic CEUS and perceived less resistance to its application in clinical practice, they would form favorable attitudes and perceived behavioral control, which in turn improved their intentions to adopt corresponding behaviors [42,43]. Thus, it reminds us that more importance can be stressed on taking measures to make clinicians' attitudes more positive toward regarding technologies and optimize their evaluation of the use. ...
Article
Full-text available
Background Medical consortiums have been extensively established to facilitate the integration of health resources and bridge the technical gap among member institutions. However, some commonly appropriate technologies remain stagnant in subordinate hospitals, although they have been routinely applied in leading hospitals. Besides, the mechanism underlying differences in clinicians’ adoption behavior at different levels of institutions was unknown. Therefore, this study aimed to investigate the differences in influencing mechanisms of clinicians’ hepatic contrast-enhanced ultrasound technology (CEUS) utilization behavior between leading and subordinate hospitals within medical consortiums, thus providing clues for expanding effective and appropriate technologies within integrated care systems. Methods A self-designed scale was developed based on the theory of planned behavior (TPB). A multistage sampling method was applied to investigate clinicians who were aware of CEUS and worked in liver disease-related departments within the sampled medical institutions. The final sample size was 289. AMOS 24.0 software was used to construct multi-group structural equation modeling (SEM) to validate the hypotheses and determine the mechanism of hepatic CEUS utilization. Results It revealed that behavioral intention significantly influenced adoption behavior, regardless of whether it was in leading hospitals or subordinate hospitals (β = 0.283, p < 0.001). Furthermore, behavioral attitude (β = 0.361, p < 0.001) and perceived behavioral control (β = 0.582, p < 0.001) exerted significant effects on adoption behavior through behavioral intention. However, in leading hospitals, subjective norm had a significant positive effect on behavioral intention (β = 0.183, p < 0.01), while it had a significant negative impact on behavioral intention in the subordinate hospitals (β = -0.348, p < 0.01). Conclusion To effectively translate the adoption intention into actual behavior, it is recommended to elucidate the demand and facilitators involved in the process of health technology adoption across leading and subordinate hospitals. Additionally, bolstering technical support and knowledge dissemination within subordinate hospitals while harnessing the influential role of key individuals can further enhance this transformative process.
... The semi-structured interview guide (Supplementary Material S1) was developed by experts in clinical medicine and public health and was informed by previous studies [21,[28][29][30]. The interview guide covered demographic information, the incidence and treatment of URTIs in primary healthcare settings, practices of antibiotic prescribing, and influences of clinical uncertainty on antibiotic prescribing. ...
Article
Full-text available
Objective: This study aimed to explore how clinical uncertainty influences antibiotic prescribing practices among township hospital physicians and village doctors in rural Shandong Province, China. Methods: Qualitative semi-structured interviews were conducted with 30 township hospital physicians and 6 village doctors from rural Shandong Province, China. A multi-stage random sampling method was used to identify respondents. Conceptual content analysis together with Colaizzi’s method were used to generate qualitative codes and identify themes. Results: Three final thematic categories emerged during the data analysis: (1) Incidence and treatment of Upper Respiratory Tract Infections (URTIs) in township hospitals and village clinics; (2) Antibiotic prescribing practices based on the clinical experience of clinicians; (3) Influence of clinical uncertainty on antibiotic prescribing. Respondents from both township hospitals and village clinics reported that URTIs were the most common reason for antibiotic prescriptions at their facilities and that clinical uncertainty appears to be an important driver for the overuse of antibiotics for URTIs. Clinical uncertainty was primarily due to: (1) Diagnostic uncertainty (establishing a relevant diagnosis is hindered by limited diagnostic resources and capacities, as well as limited willingness of patients to pay for investigations), and (2) Insufficient prognostic evidence. As a consequence of the clinical uncertainty caused by both diagnostic and prognostic uncertainty, respondents stated that antibiotics are frequently prescribed for URTIs to prevent both prolonged courses or recurrence of the disease, as well as clinical worsening, hospital admission, or complications. Conclusion: Our study suggests that clinical uncertainty is a key driver for the overuse and misuse of prescribing antibiotics for URTIs in both rural township hospitals and village clinics in Shandong province, China, and that interventions to reduce clinical uncertainty may help minimize the unnecessary use of antibiotics in these settings. Interventions that use clinical rules to identify patients at low risk of complications or hospitalization may be more feasible in the near-future than laboratory-based interventions aimed at reducing diagnostic uncertainty.
Article
Full-text available
Background The global burden of type 2 diabetes has significantly increased, leading to a considerable impact on healthcare systems worldwide. While the advent of mobile healthcare has provided some relief by addressing the shortage of certain medical resources, its adoption among the Chinese population remains relatively low. To extend the benefits of mHealth to a greater number of Chinese diabetic patients, it is essential to investigate the factors that influence their willingness to utilize it and implement targeted interventions based on these influencing factors. The Technology Acceptance Model (TAM) is widely employed to examine users' ultimate usage behaviors, and previous studies have indicated the potential relevance of the Perceived Risk (PR) theory and the eHealth Literacy Theory to users' usage behaviors. Objective Our objective was to investigate the determinants that affect the willingness of Chinese patients diagnosed with type 2 diabetes patients to utilize digital disease management applications (DDMAs). Methods We conducted a cross-sectional study of patients with type 2 diabetes in three tertiary general hospitals in Chengdu using questionnaires designed by the investigators. Participants were sampled using a convenience sampling method. The questionnaire comprised three sections: socio-demographic profile and medical history; current awareness and willingness to use digital disease management applications; and the current level of e-health literacy. Structural equation modeling was employed to assess the impact of patient awareness of DDMAs and e-health literacy on the willingness to use such DDMAs. Results (1) Patients' attitudes toward using DDMAs were significantly influenced by perceived ease of use (β = 0.380, P < 0.001) and perceived usefulness (β = 0.546, P < 0.001); (2) Electronic health literacy exerted a significant impact on patients' perceived usefulness (β = 0.115, P = 0.018) and perceived ease of use (β = 0.659, P < 0.001); (3) Patients' willingness to use was significantly influenced by perceived usefulness (β = 0.137, P < 0.001) and use attitude (β = 0.825, P < 0.001). Conclusions The present research findings hold both theoretical and practical significance, and can serve as a guide for healthcare practitioners and researchers to gain a deeper comprehension of the acceptance of digital disease management applications (DDMAs) among type 2 diabetes patients.
Article
Full-text available
Background: Nowadays, irrational use of antimicrobials has threatened public health. It's necessary to expand the use of clinical practice guideline (CPG) on antimicrobial for facilitating the proper use of antimicrobial. However, the utilization status of CPG on antimicrobial and the influencing factors, especially the ones at the organizational level, remain largely unknown. Methods: A cross-sectional questionnaire survey was conducted on a sample among physicians from 16 public hospitals in the eastern, central and western parts of China. A multilevel regression model was employed to examine factors associated with physicians' utilization of CPG on antimicrobial. Results: A total of 815 physicians were included in this study. About 80% of the surveyed physicians reported their adherence to the CPG on antimicrobial. Dimensions of "subjective norm", "perceived risk" and "behavioral intention" from the domain of physician belief, a dimension of "ease of use" from the domain of CPG traits, and dimensions of "top management support" and "organization & implementation" from the domain of hospital practice were significantly associated with physicians' utilization of CPG on antimicrobial. And except for working department, most demographics characteristics of the physician were not found to be significantly related to the CPG use. In addition, it also showed that region is a significant factor affecting physicians' CPG use. Conclusions: This study depicted the current status of CPG on antimicrobial and comprehensively identified its potential determinants not only from the three domains at the individual level, such as physician belief, but also from the location region at the organizational level. The results will provide a direct reference for the implementation of CPG on antimicrobial.
Article
Full-text available
Background: Irrational use of antibiotics is a major driver of development of antibiotic resistance, which heavily threatens population health worldwide. Understanding the mechanism of physician's antibiotic prescribing decisions is increasingly highlighted to promote prudent use of antibiotics. Therefore, the current study aimed to fill the gap, modelling physician's antibiotic prescribing and identifying the potential intrinsic and external determinants of antibiotic prescribing in primary care. Methods: A total of 428,475 prescriptions from 499 prescribers in 65 primary care facilities in Hubei of China were audited. Teixeira Antibiotic Prescribing Behavioral Model (TAPBM) was referred as theoretical basis to identify intrinsic and external predictors of antibiotic prescriptions. A questionnaire survey was conducted, covering potential physician's intrinsic determinants (knowledge, attitudes and individual characteristics) and external factors both in individual level (patient pressure, time pressure and financial incentives) and institutional level (setting and local socio-economic development). A two-level path analysis was performed linking potential determinants of antibiotic use with physician's actual practices. Results: About 44.28% of the prescriptions contained antibiotics, with 9.28% containing two or more antibiotics. The multi-level path analysis revealed that knowledge was a significant predictor of attitudes (β = 0.154, p < 0.05), but higher knowledge and attitudes failed to translate into antibiotic prescribing practices ((β = - 0.076 - 0.039, p > 0.05). Instead, external factors played a more important role and physician's antibiotic use was significantly associated with patient pressure (β = 0.102, p = 0.022), time pressure (β = - 0.164, p = 0.002), financial incentives (β = - 0.133- - 0.155, p = 0.027) and institutional environments (rural area, β = 0.408, p = 0.002; and high socioeconomic setting, β = - 0.641 - -0.578, p < 0.001 ). The prescribers who were male (β = - 0.168, p = 0.007) or had lower qualification (β = - 0.114, p = 0.028) were also more likely to prescribe antibiotics than others. Conclusion: Antibiotic prescribing practices are complex process and associated with both intrinsic (prescriber) and external (patients and institutional environment) factors. A systematic approach is required to curb over-prescription of antibiotics. Apart from educating prescribers, it is equally important, if not more, to educate patients, break incentives and nurture professional culture within organization to reduce the overuse of antibiotics.
Article
Full-text available
The aim of this paper is to measure the knowledge and attitudes of primary care physicians toward antibiotic prescriptions and their impacts on antibiotic prescribing. A questionnaire survey was conducted on 625 physicians from 67 primary care facilities in Hubei, China. Structural equation modelling (SEM) was applied to test the theoretical framework derived from the Knowledge, Attitudes, and Practices (KAP) theory. Physicians’ knowledge, five sub-types of attitudes, and three sub-types of behavioral intentions towards antibiotic use were measured. Physicians had limited knowledge about antibiotic prescriptions (average 54.55% correct answers to 11 questions). Although they were generally concerned about antibiotic resistance (mean = 1.28, SD = 0.43), and were reluctant to be submissive to pressures from consumer demands for antibiotics (mean = 1.29, SD = 0.65) and the requirements of defensive practice (mean = 1.11, SD = 0.63), there was a lack of motivation to change prescribing practices (mean = −0.29, SD = 0.70) and strong agreement that other stakeholders should take the responsibility (mean = −1.15, SD = 0.45). The SEM results showed that poor knowledge, unawareness of antibiotic resistance, and limited motivation to change contributed to physicians’ high antibiotics prescriptions (p < 0.001). To curb antibiotic over-prescriptions, improving knowledge itself is not enough. The lack of motivation of physicians to change needs to be addressed through a systematic approach.
Article
Full-text available
Objectives To explore patients’ or parents of child patients’ understanding of antibiotic resistance and aspects of resistance such as resistance reversibility and its spread among those in close proximity, along with how this may influence attitudes towards antibiotic use for acute respiratory infections (ARIs). Design Qualitative semistructured interview study using convenience sampling and thematic analysis by two researchers independently. Setting General practices in Gold Coast, Australia. Participants 32 patients or parents of child patients presenting to general practice with an ARI. Results Five themes emerged: (1) antibiotic use is seen as the main cause of antibiotic resistance, but what it is that becomes resistant is poorly understood; (2) resistance is perceived as a future ‘big problem’ for the community, with little appreciation of the individual impact of or contribution to it; (3) poor awareness that resistance can spread between family members but concern that it can; (4) low awareness that resistance can decay with time and variable impact of this knowledge on attitudes towards future antibiotic use and (5) antibiotics are perceived as sometimes necessary, with some awareness and consideration of their harms. Conclusions Patients’ or parents of child patients’ understanding of antibiotic resistance and aspects of it was poor. Targeting misunderstandings about resistance in public health messages and clinical consultations should be considered as part of a strategy to improve knowledge about it, which may encourage more consideration about antibiotic use for illnesses such as ARIs.
Article
Full-text available
Advocating for improving workplace safety and health has gained substantial support in recent years. The medical industry is a high-risk industry and receives considerable public attention. This study used an integrative approach as a starting point and combined the contextual factors of an organization: perceived organizational support, safety climate, social influence, and shared decision making. Subsequently, the effects of these factors on preventive action and safety satisfaction were investigated. This study surveyed employees of two hospitals, one in Northern Taiwan and one in Eastern Taiwan, collecting valid data from 468 respondents. Structural equation modeling (SEM) was used to verify our research framework. The finding indicates that (1) All hypotheses proposed in this study were supported. (2) The overall goodness of fit of the model was excellent, and the explained variance of the outcome variables was high. (3) Safety climate had the strongest total effects on preventive action and safety satisfaction simultaneously, whereas preventive action had the strongest direct effect on safety satisfaction. The objective of this study was to obtain empirical conclusions and make suggestions for academic theory and clinical practice. The findings may serve as a reference for future research and for scholars and practitioners, enabling the creation of healthy workplaces and, thus, a brighter future.
Article
Full-text available
This paper aims to examine the factors influencing older Chinese’s social networking site (SNS) use and to help older people live a better life in this technology-oriented world. A proposed model composed of eight hypotheses was built according to Diffusion of Innovation Theory and was tested via 726 valid data points. The empirical results show that technical compatibility and relative advantages as technical factors and Internet self-efficacy as a personal cognitive factor promote older people’s SNS use. Technical complexity as a technical factor and Internet anxiety as a personal cognitive factor hinder older people’s SNS use. Social support as a facilitating condition alleviates the negative effects of technical complexity and Internet anxiety and enhances the positive effect of Internet self-efficacy. Gender differences and health status differences are significant. Older men are more likely to use SNSs than older women; older adults in poor physical health condition are more likely to use SNSs compared with those in good health. Compared with older people in Western countries, older Chinese’s SNS use does show some differences: 1) gender differences are significant with males having a stronger intention to use SNSs; 2) older people face severe digital divide because technical factors show stronger power in predicting their SNS use; 3) older people need social support to assist their SNS use, but their social support mainly comes from age peers rather than young people.
Article
Full-text available
Background The aim of this study was to investigate whether marketed antibiotics package sizes are in accordance with treatment durations recommended in guidelines for prescribing antibiotics in sore throat and urinary tract infections. Methods National drug database was searched with limitation to Antibacterials for systemic use. Formulations which did not have pre-specified dosage unit by the manufacturer were excluded (e.g. powders for oral solutions). The final list contained 94 drugs with 23 different active substances. This list was then cross-referenced with selected antimicrobial prescribing guidelines provided by Intersectoral Society for Antibiotic Resistance Control (ISKRA), National Institute for Health and Care Excellence (NICE) and The Infectious Diseases Society of America (IDSA). Results Seven packages matched ISKRA guidelines on sore throat while 16 were mismatched. Considering drug packages under reimbursement, 3 matched ISKRA guidelines and 8 were mismatched. Only 3 packages matched IDSA guidelines for comparable indications, and 18 were mismatched. When considering NICE guidelines there were 5 mismatched and only one package that was in accordance with the guidelines. ISKRA guidelines for urinary tract infections matched 23 packages and mismatched 58 packages. IDSA guidelines for urinary tract infections matched one package and were mismatched in 15 cases. Conclusions One of the causes of leftover antibiotics is poor accordance of antibiotic package size with treatment recommendation duration. This should be identified as a potential target for reduction of excess antibiotics in the community. Measures that promote patient adherence to therapy and patient education should be considered essential to manage proper handling of leftover antibiotics.
Article
Full-text available
Abstract Background Over-prescription of antibiotics is prevalent all over the world, contributing to the development of antibiotic resistance. The importance of understanding how physicians prescribe antibiotics is increasingly highlighted for the purpose of promoting good practice. This study aimed to identify factors that shape the antibiotic prescribing behaviors of physicians in primary care based on the theory of planned behavior (TPB). Methods Data were collected from 503 prescribers within 65 primary care facilities in Hubei, tapping into four behavioral aspects leading to antibiotic prescribing based on TPB, namely, attitudes (the degree to which a prescriber is in favor of the use of antibiotics), subjective norms (perceived social pressure to which a prescriber is subject in relation to antibiotic prescriptions), perceived control of behaviors (how easy a prescriber feels in making a rational decision on antibiotic prescriptions) and intentions (the degree to which a prescriber is willing to prescribe antibiotics). A total of 440,268 prescriptions were audited to assess physician antibiotic prescribing practices. The four behavioral constructs were further linked with physician’s actual use of antibiotics using structural equation modelling (SEM) based on TPB. Results On average, 40.54% (SD = 20.82%) of the outpatient encounters resulted in a prescription for an antibiotic given by the participants and 9.81% (SD = 10.18%) of the patients were given two or more antibiotics. The participants showing a more favorable attitude toward antibiotics had a higher intention to prescribe antibiotics (β = 0.226, p
Article
Rationale and Aims Antibiotic development was a major breakthrough in defeating infections; however, their vast use has led to antimicrobial resistance (AMR) causing mortality, morbidity, and financial burden worldwide. Considering the limited introduction of newer antimicrobials to overcome resistance patterns, sufficient knowledge of their use can help manage this issue. Antimicrobial stewardship programmes (ASPs) with the mainstay of education can be a good resolution. The aim of this study was to seek aspects in which knowledge regarding antibiotics is lacking at our institutions. Materials and Methods This cross‐sectional study performed in Shiraz, South of Iran, was designed as a knowledge, attitude, and practice (KAP) study. A self‐administered questionnaire consisting of 15 questions was designed and handed out to health care workers including infectious disease practitioners, surgeons, internal medicine specialists and residents, general practitioners, medical students, and microbiology lab technicians and PhD graduates. Difference in response to questions was evaluated between the practitioner and nonpractitioner groups. Results Completed questionnaires were collected (n = 126). According to the results, most participants (88.1%) agreed on establishment of local guidelines. Majority (94.4%) also believed that education regarding antibiotics can help reduce AMR. Good patient care was not believed to be impaired by limiting use of antibiotics (72.2%). A significant difference in the practitioner and nonpractitioner groups' practice score was observed. Conclusion In our study, knowledge deficit was observed in some aspects of AMR. We can conclude that more practice and education are needed in ASP for the better performance in reducing resistant patterns.
Article
As hospitals increase their reliance on healthcare information technology to deliver services, there is a growing need to understand how to promote E-Health innovation usage within a hospital. Drawing on institutional theory and top management perspectives, we develop a theoretical model that explains how E-Health usage is influenced by external institutional forces and top management support. Three types of institutional forces: mimetic, coercive and normative pressures and two actions: top management beliefs and E-Health championing by which top management champions E-Health usage are identified and examined. Our empirical results show: 1) mimetic and coercive pressures positively affect top management beliefs and mimetic pressure also positively affects E-Health championing, 2) the effect of mimetic pressure on top management beliefs and E-Health championing is significantly stronger than other pressures, 3) both top management beliefs and E-Health championing promote E-Health usage, and 4) institutional forces' influence on E-Health usage is mediated by top management support. These findings highlight the important role of top management support in mediating the effect of institutional forces on E-Health usage and provide insight into how hospitals govern the institutional forces that drive top management support for E-Health innovations, thereby leading to actual E-Health usage.