Barriers to and facilitators of adherence to evidence-based standard antimicrobial treatment guidelines among physicians in Ethiopia: a formative qualitative study

Rational antimicrobial prescribing is critical to curb antimicrobial resistance, yet adherence to standard antimicrobial treatment guidelines remains inconsistent in Ethiopia. Understanding the barriers and facilitators influencing physicians’ adherence is essential to inform context-appropriate interventions. We conducted a formative qualitative study from April to June 2023 in 20 public hospitals across four Ethiopian regions. Using maximum variation purposive sampling, 47 physicians participated in in-depth interviews. Data were analyzed using the Theoretical Domains Framework embedded within the COM-B model, with thematic coding in MAXQDA and reporting guided by COREQ. Physicians faced multiple barriers to standard antimicrobial treatment guidelines adherence. The guidelines were often bulky, outdated, and misaligned with patient needs. Limited training, low confidence, and resistance from senior clinicians further reduced adherence. Delayed dissemination, restricted access to medicines, heavy clinical workloads, and inconsistent practices in private facilities compounded these challenges. Facilitators supporting adherence included peer collaboration, routine clinical audits, trust in locally developed guidelines, and professional motivation. Study participants recommended developing smartphone application of standard antimicrobial treatment guidelines for point-of-care access. Study participants highlighted digital solutions, such as mobile STG applications, to enhance accessibility and recommended interventions including training, digital access, audits, and policy enforcement. Adherence to standard treatment guidelines is influenced by individual, institutional, and system-level factors. Updating and digitalizing guidelines, integrating adherence into continuous professional development training, strengthening institutional support, and implementing policy measures are key strategies to improve adherence and rational antimicrobial prescription.