Background: Antimicrobial resistance poses a serious threat to global public health. Behaviours such as inappropriate antibiotic use in hospitals have contributed to this problem, and evidence-based interventions are urgently needed to improve prescribing practices in acute settings. Previous behaviour change interventions aimed at reducing inappropriate antibiotic use in hospitals have been sub-optimal and lacked details on their development.

Methods: Guided by the recommendations of the 2008 MRC Framework for Complex Interventions, intervention development followed a phased approach, including a systematic review and meta-ethnography, two qualitative studies with a total of 35 participants, and the development and operationalisation of the intervention content. A meta-ethnography, the first theoretical stage, synthesised 15 qualitative papers and provided an understanding of the contextual determinants influencing antibiotic prescribing in acute hospitals. The resulting conceptual model reflected how these challenges operate on both micro- and macro-level, highlighting key areas for improvement. Central to the design of an effective intervention was the generation of a robust theoretical basis using the Behaviour Change Wheel. The selection of an intervention content was guided by the APEASE criteria and coded according to an established Behaviour Change Technique Taxonomy. Healthcare professionals and patient representatives were involved at all stages of intervention design and interpretation. Focus groups carried out with key stakeholders filled in gaps in the literature and enabled modelling of the initial draft of the intervention. The optimisation phase, including assessing the intervention acceptability and suitability for clinical practice, was conducted using semi-structured interviews.

Results and Conclusions: A digital antibiotic review tracking toolkit (DARTT), a complex, multifaceted behaviour change intervention to improve antibiotic use in acute hospitals, was developed using systematic methods. This work addresses a gap in the literature regarding how to develop behaviour change interventions that are grounded in theory and acceptable for the target group. Findings from this work are potentially transferable to a variety of behaviour change interventions and clinical settings.