A behavioural intervention targeting the use of antibiotics in residential aged care.

The intervention will include: 1) social norm feedback to the manager of each residential aged care (RAC) home about antibiotic use at their home compared to other homes in the study; 2) public commitment posters; 3) consumer information. The intervention bundle was co-developed with the aged care providers through a consultation process and workshops. Each of the 46 RAC homes will receive the intervention bundle three times (on a quarterly basis) with three rounds of social norm feedback. The Stepped-wedge cluster randomised controlled trial will be conducted over a 15-month period: each “step” will be of 3-months duration. Social norm feedback Social norm feedback will be collated by members of the research team and delivered in the form of a letter and email addressed to the RAC home’s residential manager on a quarterly basis. The content of the letter was informed by guidelines for the design of audit and feedback interventions (Jamtvedt et al (2019) Audit and Feedback as a Quality Strategy. Available from: https://www.ncbi.nlm.nih.gov/books/NBK549284/) and evidence on social norm feedback from the behavioural economics literature (Beatty and Buttenheim (2023). The Behavioral Economics Toolkit: Policy Levers and Intervention Strategies. Available from: https://www.ncbi.nlm.nih.gov/books/NBK593511/). The key elements included to support the effectiveness of social norm feedback will be: i) a performance target; ii) actionable advice to improve performance; iii) an injunctive norm; iv) respected signatory; v) multiple rounds of feedback. Data presented and performance target: The main message contained in the letter will graphically present antibiotic days of therapy per 1000 resident days (DOT/1000 days) for the home each month for the preceding three months compared to the target performance. The target performance will be the mean of the lowest decile of DOT/1000 days of intervention RAC homes. Performance metrics will be calculated from electronic health data that will be extracted on a quarterly basis from aged care providers’ information systems, including medication administration records (e.g., the medicines each resident receives daily) and resident profile data which comprises demographic information (e.g., age, sex), and health conditions (e.g., dementia, Parkinson’s disease). Actionable advice: The social norm feedback will comprise two actions that can be taken to reduce the DOT/1000 days. Firstly, the feedback will contain the message that ‘Shorter is better’. That is, when antibiotics are used, they should be used for a duration of 5 days for most infections. The percentage of antibiotic courses in the RAC home during the last quarter that were longer than guidelines, along with the guideline recommendations for duration of treatment for common infections (from Therapeutic Guidelines - Antibiotic https://www.tg.org.au) will be presented. Secondly, there will be a message encouraging reduced use of antibiotics, with a reminder that antibiotics may cause adverse effects and are ineffective against key infections (e.g. viral infections). Injunctive norm: We will provide clear messaging about whether the home’s performance is perceived positively or negatively. There will be three messages based on the home’s level of antibiotic use. The comparison antibiotic use rates, i.e. the target performance, will be described as the ‘best performing’ homes. RAC homes with rates of antibiotic use (DOT/1000 days) within the lowest decile will be provided with a message stating ‘you are a best performer’ to support well performing homes to maintain their performance. RAC homes with DOT/1000 days in the lowest quartile (bottom 25%), that are not best performers, will be provided a message stating ‘you are close to being a best performer’. The remainder of facilities will be encouraged to improve their performance with a visual comparison of their antibiotic DOT/1000 days against the best performing homes. All feedback will a message reinforcing that ‘lower is better’. Respected signatory: The social norm feedback signatories will be unique to each aged care provider and will be leaders from within each organisation. This will increase the credibility of the feedback through local leadership support. Multiple rounds of feedback: Each RAC home will receive a total of 3 rounds of feedback. Public commitment Poster-sized commitment messages will be provided to the intervention homes to be displayed in staff areas and common spaces within each RAC home, once the intervention has been implemented (i.e. the delivery of social norm feedback has begun in the home). Posters will feature aged care staff photographs and signatures and will emphasise the organisation’s commitment to best practice use of antibiotics, including the use of antibiotics only when necessary and following treatment guidelines on the length of time antibiotics are used. Consumer information Information will be displayed and distributed to consumers (residents and their families) via digital screens in common areas, newsletters, and leaflets. Simple messages will be promoted that are consistent with key elements of the social norm feedback and public commitment, including the organisational commitment to use antibiotics only when necessary and following treatment guidelines on the length of time they are used for. A link to additional resources will be accessible via a QR code included on consumer-focussed materials. Intervention delivery: The intervention bundle will be delivered by email and post directly to the RAC home manager. Thus, intervention homes will receive electronic and hard copies of the materials. One week prior to the first intervention round, an email will be sent to the RAC managers to inform them that they will receive the intervention. Additionally, half-way through the first and second social norm feedback quarter, an email will be sent to RAC managers in the intervention group to remind them that another round of feedback will be delivered in a few weeks. Process evaluation: Semi-structured interviews will be conducted in a sub-sample of intervention RAC homes at 3-months and 9-months after the first round of feedback to assess stakeholder experiences of the intervention bundle and how they change over time. Interview questions will explore exposure to, and interactions with, intervention materials, including stakeholder understanding and impressions of the messages, and any actions related to exposure to the materials.