A qualitative investigation into hospital-based antimicrobial stewardship programs across Ho Chi Minh City, Vietnam, has revealed that clinical implementation is governed by complex interactions among institutional workflows, professional hierarchies, and misaligned treatment guidelines. In a study conducted across twelve hospitals, investigators interviewed physicians and clinical pharmacists to determine the underlying behavioral factors that influence routine antibiotic oversight. The research revealed that while healthcare professionals demonstrate widespread support for stewardship objectives and recognize the urgency of curbing antimicrobial resistance, daily execution remains obstructed by significant operational and behavioral obstacles. These challenges include unadapted international clinical protocols, burdensome manual pre-authorization mandates, hierarchical clinical dynamics, and restricted decision-making authority among clinical pharmacists. By applying established behavioral science frameworks, the study identified nine priority domains spanning psychological capabilities, physical and social opportunities, and reflective motivations that must be targeted to establish functioning antimicrobial oversight within the Vietnamese healthcare system.

The operational necessity for structured hospital antimicrobial stewardship programs in Vietnam is underscored by severe epidemiological challenges regarding antimicrobial resistance. Vietnam currently records some of the highest resistance frequencies across Asia, with regional surveillance data from the Asian Network for Surveillance of Resistant Pathogens documenting resistance rates of 92.0 percent for penicillin and 92.1 percent for erythromycin among eleven surveyed countries. Furthermore, data from the Survey of Antibiotic Resistance demonstrated that resistance rates among Streptococcus pneumoniae and Haemophilus influenzae isolates in Vietnam exceeded those documented in neighboring nations including Cambodia, Singapore, and the Philippines. These elevated burdens occur against a backdrop of global estimates attributing approximately 4.95 million deaths to antimicrobial resistance in 2019. In response, Vietnam’s Ministry of Health introduced national regulatory guidance in 2016 and updated it in 2020, mandating that hospitals across all administrative tiers establish dedicated stewardship committees and integrate stewardship performance into routine hospital quality evaluations.

Despite this regulatory mandate, nationwide integration of antimicrobial stewardship programs has remained deeply uneven and fragmented. Data referenced by the authors indicate that out of 655 hospitals operating across Vietnam, only 144 facilities had successfully initiated formal antimicrobial stewardship programs. Even among the minority of institutions that established these frameworks, improvements in antibiotic utilization varied substantially, and few facilities managed to satisfy comprehensive national stewardship criteria. Previous regional studies identified multiple contributing factors to this execution gap, including variable hospital leadership engagement, uncertain legitimacy of clinical pharmacist interventions within physician-directed care teams, patient pressures, and marked infrastructural disparities across hospital tiers. However, the specific behavioral mechanisms that govern how physicians and pharmacists negotiate antibiotic decisions under routine operational constraints had remained largely uncharacterized, prompting the research team to investigate the daily clinical determinants operating within Ho Chi Minh City’s dense hospital network.

To rigorously examine these professional dynamics, investigators carried out semi-structured qualitative interviews between April and June 2024, recruiting practitioners from across the medical infrastructure of Ho Chi Minh City. The municipal healthcare environment encompasses approximately 162 hospitals across central, city, provincial, district, military, and private administrative sectors. The investigators employed a participant-level maximum-variation sampling strategy, recruiting physicians and clinical pharmacists who possessed at least one full year of direct experience executing antimicrobial stewardship programs. Recruitment combined researcher networks for initial key contacts with iterative snowball sampling to expand reach across institutions. Ultimately, fifty healthcare professionals were invited to participate, of whom nine either declined or did not respond. Data collection continued alongside ongoing analysis until theoretical saturation was reached at thirty-nine interviews, after which two additional interviews were completed to ensure thematic comprehensiveness, yielding a final analytical sample of forty-one participants.

The final cohort of forty-one participants included twenty-three clinical pharmacists representing 56.0 percent of the sample and eighteen physicians representing 44.0 percent. These practitioners were drawn from twelve medical facilities across Ho Chi Minh City, consisting of eleven public hospitals accounting for thirty-seven participants and one private hospital accounting for four participants. In terms of institutional scope, seven hospitals were general facilities and five were specialized institutions, spanning central, provincial, and district administrative tiers. Female practitioners comprised 61.0 percent of the cohort, and 75.6 percent possessed between one and five years of professional clinical experience. Individual interviews exhibited a median duration of thirty minutes, within an interquartile range of 18 to 37 minutes and a total span from 13 to 54 minutes. Ethical approval was granted by the Research Ethical Committee at the University of Medicine and Pharmacy at Ho Chi Minh City, and all transcripts were transcribed verbatim in Vietnamese before undergoing independent double-coding.

The study’s analytical architecture relied on the integration of two complementary theoretical structures: the Behaviour Change Wheel and the Theoretical Domains Framework-14. Central to the Behaviour Change Wheel is the COM-B model, which conceptualizes any health-related action as an interacting product of Capability, Opportunity, and Motivation. To evaluate clinical decisions with granular precision, the researchers mapped these three core components onto the fourteen discrete behavioral categories of the Theoretical Domains Framework-14. Qualitative data were examined through parallel deductive coding using the theoretical frameworks alongside inductive thematic analysis to capture unanticipated contextual dynamics. Three researchers double-coded all transcripts, rotating assignment schedules every four to five days to eliminate individual analytical bias, with interpretive disagreements resolved through structured consensus discussions with a senior investigator. Investigator and methodological triangulations were systematically applied, and the analytical corpus was subsequently translated into English and verified by a social science expert under the Consolidated Criteria for Reporting Qualitative Research guidelines.

The empirical findings revealed prominent facilitators that actively support stewardship behaviors within Vietnamese hospitals. Participants universally emphasized that accessible hospital resources and authoritative reference literature substantially aided clinical task execution. The presence of hospital-level, national, and international guidelines provided clinicians with structured technical guidance for rational drug selection. Furthermore, supportive institutional policies, such as recurring staff training sessions and the integration of electronic clinical software, measurably improved professional awareness and procedural efficiency. Clinical pharmacists also highlighted the value of routine departmental assessments, in which stewardship teams audited approximately ten patient medical charts per clinical department to evaluate antibiotic appropriateness before reporting collective findings at hospital-wide conferences. Participants acknowledged that antimicrobial stewardship programs enhance patient treatment efficacy while suppressing drug resistance. Clinicians demonstrated strong professional motivation and personal commitment, while active interprofessional communication, mentorship from senior colleagues, and hospital leadership backing fostered collaborative alignment between prescribing physicians and reviewing pharmacists.

Concurrently, the analysis detailed pervasive structural, operational, and interpersonal barriers that consistently disrupt stewardship adherence. A primary challenge involved the clinical reference materials themselves: numerous clinicians reported that available guidelines rely predominantly on international epidemiological data that fail to reflect local pathogen profiles and resistance patterns in Vietnam. Discrepancies among contradictory clinical references generated decision-making ambiguity. Operational workloads and time constraints imposed further impediments; clinical pharmacists reported becoming overwhelmed by the expansive volume of patient monitoring indicators, while physicians described pre-authorization protocols for restricted reserve antibiotics as excessively bureaucratic and time-consuming. These approval workflows require multi-level documentation that frequently delays therapy, prompting some physicians to deliberately prescribe lower-efficacy or non-restricted antibiotics simply to circumvent administrative burdens. Inadequate hospital staffing, medication shortages, inconsistent information technology systems, and irregular stewardship education for physicians exacerbated these operational strains.

The qualitative data uncovered distinct interpersonal frictions and professional boundary tensions that compromise collaborative practice. Although clinical pharmacists possessed comprehensive familiarity with national stewardship regulations, their practical authority was structurally constrained because Vietnamese medical law designates treating physicians as solely responsible for legal medical records. Consequently, clinical pharmacists described intense frustration when their evidence-based prescribing recommendations were dismissed as overly theoretical or lacking clinical depth by physicians who retained exclusive decision-making authority. In turn, several physicians admitted to limited familiarity with their institutional stewardship duties, choosing instead to rely on individual clinical intuition and unstandardized personal experience rather than established guidelines. Professional hierarchies also silenced junior medical personnel, who routinely felt pressured to duplicate the prescribing selections of department seniors. These professional challenges were further compounded by external pressures, including patient demands for antimicrobials and financial constraints stemming from partial national health insurance coverage, which forced physicians to prescribe cheaper, sub-optimal therapies for impoverished patients.

By systematically synthesizing these qualitative findings against the theoretical frameworks, the investigators mapped all empirical factors across the fourteen domains of the Theoretical Domains Framework-14 and prioritized nine specific domains for targeted behavioral intervention. These priority domains comprised Knowledge, Skills, Memory, attention and decision processes, and Behavioural regulation under the COM-B Capability construct; Environmental context and resources alongside Social influences under the Opportunity construct; and Social/professional role and identity, Beliefs about capabilities, and Beliefs about consequences under the Motivation construct. Five domains—Reinforcement, Emotion, Goals, Intentions, and Optimism—were excluded from immediate intervention targeting due to resource intensity or substantial thematic overlap. While the study was bounded by the exclusion of nursing, microbiology, and infection control personnel and relied on individual interview self-reporting, its theoretical mapping establishes an empirical framework for designing behavior change techniques, institutional policy categories, and decision-support tools tailored directly to Vietnamese hospitals.

Subject of Research: Qualitative investigation of behavioral determinants influencing hospital antimicrobial stewardship implementation in Vietnam

Article Title: Antimicrobial stewardship programme implementation in Ho Chi Minh City, Vietnam: a qualitative study to understand healthcare professional behaviours

Article References: Quan, P. B., Truong, U. T. U., Ho, D. N., Hughes, C., & Nguyen, H. Q. (2026). Antimicrobial stewardship programme implementation in Ho Chi Minh City, Vietnam: a qualitative study to understand healthcare professional behaviours. Antimicrobial Resistance & Infection Control, 15(1), Article 132. https://doi.org/10.1186/s13756-026-01798-5

Image Credits: AI Generated

DOI: 10.1186/s13756-026-01798-5

Keywords: Antimicrobial stewardship, Antibiotic resistance, Healthcare professional behaviours, Ho Chi Minh City, Hospital pharmacy, Clinical pharmacists, Theoretical Domains Framework, Behaviour Change Wheel, COM-B model, Vietnam healthcare, Qualitative semi-structured interviews, Prescribing practices, Health insurance coverage, Prior authorization, Interprofessional collaboration, Clinical guidelines, Maximum-variation sampling