Table 5. The data from the interviews by theme.

Theme	Quote
T1 Government and state infrastructure are perceived as determinants of ASP	Q1	‘Now in Indian scenario access to healthcare is a problem, very many places, the prescriber is alternative medicine. First contact is an alternate medicine, first contact is a quack and first contact is a nurse, first contact is a pharmacist, a trained or an untrained pharmacist.’ Medical Superintendent, India Hospital N
	Q2	‘…people come from many … different hospitals after receiving different courses of antimicrobials also. So, it’s very difficult to grow them [microbiological cultures] also because it’s all pre-treated with antimicrobials.’ Consultant Microbiologist, India Hospital M
	Q3	‘However, we can mention pharmaceutical representatives who have great influence on the prescription of medicines, particularly antimicrobials. There are not enough therapeutic protocols in the hospital, so I think that these representatives can easily influence antimicrobial prescription.’ Consultant, Burkina Faso Hospital X
	Q4	‘When I was part of the government defender body I realised it is so difficult to work because they are a multinational with money, they can change the government but you cannot just keep on saying that, it’s so difficult it’s a mafia…have identified 24 manufacturers who are producing counterfeit drug, it may be small but there is an effort.’ Medical Superintendent, India Hospital N
	Q5	‘… ultimately none of us wants to lose what for us was going to be £750,000 of income if we didn’t achieve the target. So, it was again a hearts and minds approach. It wasn’t, we’re going to track down every bad prescription and tell people off and report them to the chief executive. It was, we’re going to go out and present people the facts and the information, make a compelling argument, and appeal to their good nature to cooperate and be part of this push all together. And that worked, it seems to have worked. So that we’ve been monitoring the trends and we’re, on track to meet the CQUIN.’ Consultant, England Hospital U
	Q6	‘I fear, personally, I think it’s negatively impacted the pharmacist’s job role within the antimicrobial team. Our role pretty much now is to drive the CQUIN agenda and make sure that we’re meeting all the targets, so we really have to pull back from what I think is an important day to day role so attending ward rounds, and we just don’t have time to do that anymore, we’re purely office based trying to hit the CQUIN targets.’ Pharmacist, Hospital S
	Q7	…..people [referring to the body responsible for CQUIN targets]… feel that they have an informed opinion or an opinion which is worthwhile listening to and acting on, which you wouldn’t ask a surgeon, a heart surgeon, you wouldn’t say to a heart surgeon well I think you should be doing this sort of clinical practice…. that sort of CQUIN would come from within the specialty itself…. as an illustration, David Cameron saying we’re going to reduce our inappropriate antimicrobial prescribing by 50% by 2020. How do you know what’s inappropriate? It’s all very well, it all sounds really excellent stuff, but it opens up so many questions that are impossible to answer. I was down the Department of Health and we were looking at how we’re going to measure inappropriate prescribing … and the universal answer was well we can’t, we don’t know, how would you know whether it’s inappropriate or not?’ Consultant, Hospital S
	Q8	‘To set up a guideline, anyone can do it. What I would suggest is everyone come up with antibiograms and make it, mandatory is the word I think I can use, make it mandatory that, see, we have come up with data from South India, this is from North India, East and West, whatever, and study that in detail and the government itself should say, you have to implement this or your job is in jeopardy. Something will happen….my issue is that we all get our salary. We get our salary no matter what happens, and I’m afraid that doesn’t happen. Once you don’t do your job properly, you’re sacked. Here you are protected by the government itself because there is no point in taking the mike and talking about stewardship and government policies. You have to implement it, thinking that their job will go if they are not going to follow this.’ Professor of Microbiology, India Hospital Q
	Q9	‘…here we don’t have an active role [in ASP]. We don’t see the patients and the clinicians have no direct communication with us. But, nowadays, this antimicrobial stewardship and all are gaining importance so, at government level itself, certain initiatives are being taken under Dr X [Medical Superintendent at Hospital N]. So, this, even recently a meeting was convened at the capital of Kerala where all the head … of medical colleges … and they have met, I hope they have started discussing what could be done in view of this.’ Consultant Microbiologist, India Hospital R
	Q10	‘Also of course, there is the … structure on the Norwegian healthcare system with the Department of Health as the owner of the regional health authorities, and the Department of Health sends an order every year to the regional health authorities, this could contain both, they could demand an antimicrobial stewardship programme should be implemented in hospitals, but also this could come from the regional health authorities, and out to the other health trusts and hospitals. So that is probably the most effective way of getting antimicrobial stewardship programmes in Norwegian hospitals.’ Consultant Infectious Diseases, Norway Hospital A
	Q11	‘There is antimicrobial stewardship. It doesn’t matter who is involved but there is a stewardship programme and there is willingness to make it better. In the small hospitals, I mean less than 300 beds, or private hospitals, it’s not done because there are no specific practitioners there is no time to do it, there is no money. The reason why it is moving now is the fact that our healthcare indicators now has one dedicated to antimicrobial stewardship.’ Consultant, France Hospital F
	Q12	‘In Norway it’s hospital infections specialists who have that role in many hospitals but it’s very difficult to have a, to get doctors into that speciality. It’s very difficult. So in this hospital there are no full time hospital infection control specialists. I have a job and infectious disease specialists have a job, part time, not full time.’ Head of Microbiology, Norway Hospital C
T2 Professional boundaries decide involvement in ASP	Q13	‘In France a lot of advice is obtained from ICU [Intensive Care Units] doctors, sometimes in small hospitals ICU physicians serve as a reference for antimicrobial advice…. I think that physicians in the hospital are more confident in the advice given by an ID physician compared with advice given by a pharmacist or microbiologist.’ Consultant, France Hospital E
	Q14	Interviewer: ‘What do you think is the biggest barrier to changing people’s behaviours? From your experience?’ Participant: ‘Hierarchy. I think we need to accept that doctors are not some sort of gods. It’s like an occupation. Doctors are doctors. It’s only an occupation. Pharmacy too, everyone is important in this world.’ Consultant, France Hospital F
	Q15	‘…it’s sort of ‘are you a member of the family or no? And this is why it’s impossible for nurses to be involved. ‘She’s a nurse, she’s only a nurse’… and about pharmacist it’s also the same. When you speak to pharmacists about being involved some of the pharmacists they don’t want to be involved in the programme. They say “I am not a clinical doctor, I don’t know …do you imagine that as a pharmacist I am will call a doctor and tell them you have made a bad choice? It’s impossible!”‘ Consultant, France Hospital E
	Q16	‘But there is …. a north south divide, so the hierarchy in the north is amazing. The nurse will not be able to open her mouth and say, this is illegal, like in England [the participant had spent time training in England], the nurse will just rap my knuckles and say that, you’re doing this wrong. They won’t have the guts to say that in the north. Kerala, because the communist culture, it’s a lot better, because they have, you can’t scream at them the way they do in the north, it’s a very bad, very, very bad system.’ Surgeon, India Hospital N
	Q17	‘The [senior microbiologist] has always taught us, and it’s an approach that I've adopted, is that as microbiologists, and even as ID physician, especially here and other places where we have a consult service and we don’t have our own patients, we’re guests, and in the same way that you would expect a guest to come to your house and behave a certain way… you have to do the same thing …. so you go to the MDT [multidisciplinary team meeting] and you kind of establish a rapport … and then you rely on making an impression but also gaining their trust for them to invite you back. You can’t go along to the first meeting and tell them they’re doing everything wrong and override all their decisions.’ Consultant Microbiologist, England Hospital T
	Q18	‘If they want, we go. And if they want me to come for rounds, I go. It’s their decision. I don’t go actively from my side, because that will, that doesn’t work. They are in a different place, the whole hospital they are going around. They have other issues, they have procedures. So our timing’s … So if they want something to be done and they call me, I go, have a look at it, give my advice.’ Consultant Microbiologist, India Hospital N
	Q19	‘Here, we do not directly communicate, we send the labs to the central collection area and from there the clinicians collect, but in certain situations, when we think we really need to alert them, we call them directly. I’m not fully satisfied with the response. I think here the communication is a little bit low between the clinical side and the lab side and what I feel is, if the communication is better, there can be a significant change.’ Consultant Microbiologist, India Hospital R
	Q20	‘So what I’ve understood from this about nine years of doing this….. you need a strong support or commitment from the top administration. And when I say support, it should be visible meaning it is not that the CEO tells you in a closed door meeting ….. What I mean is that in the mortality morbidity meeting, in the CMEs [continuing medical education] of doctors, when you have the whole faculty meeting, at that time when the boss says that he’s behind you, supporting you for this, that is visible support. So we need support which is visible, like the top management talking to other people that, no, I am with this team, not just between ourselves saying that I am with you. So that is one thing which I noted which makes a difference. Consultant, India Hospital O
	Q21	‘The best in France is here. I was convinced when starting that to make a good job we had to work closely with pharmacists and microbiologists… So one of my main drivers was always to be with these collaborations. And now infection control, and it works well. I think it’s quite exemplary. I’m quite proud of that. Of the excellence of the relationships between all these partners. And I think it is particular to the team here…’ Consultant, France Hospital E
T3 Social norms and values in relation to antimicrobial decision making are determined at specialty level	Q22	‘Generally ICU’s are better at using the guidelines than other wards, and on other wards, specialties are better than general doctors and medicine is better than surgery.’ Consultant, France Hospital F
	Q23	‘We are doing some audits on surgical wards around behaviour. How they close and open wounds during the surgery… and the heads of surgery had the wedding rings and performed the surgery wearing the rings…. we fed back to them and to the head of nursing, saying “thank you for this, but we found a little problem. Doctors and nurses should have their hand free.” And within five minutes of sending this email. The head of surgery answered: ‘Doctors will never take their ring off…” Consultant, France Hospital F
	Q24	‘Like it is generally said that there is a cardiovascular thoracic surgeon, there is cardiologist, there is god in hierarchy and then there are physicians and surgeons. So these group of people they don’t talk, they don’t allow you to talk also because they do what they want to do because …. transplant surgeons and cardiovascular thoracic they don’t listen. But fortunately they have seen that our intent is ethical and intent is quality and we are not driving any programme on commercial interest…’ Medical Superintendent, India Hospital N
	Q25	‘the problem is that usually, they trust us to treat the infection but the infection also needs medical and surgical management and sometimes we are unable to change the surgical procedures for the best infection management outcomes. So, sometimes it’s difficult even if they leave us to treat infection the discussion of the surgical procedure and management is difficult to obtain. Sometimes the department gives us the trust but it is relative trust. This is very technical and strategic work and it is political and it’s about relationships, confidence etc. It takes time, years to build. Some departments are really resistant…’ Consultant, France Hospital E
	Q26	‘I find most surgeons feel it is my patient which is at stake so I must treat him irrespective of cost or whatever stakes that are there, I really don’t care about tomorrow. It’s just like global warming isn’t it? Like let me use it now, I don’t know if this is going to come a million years later, we don’t realise that some of those effects are for our children. In antimicrobials I feel it’s in our very own patient as well.’ Surgeon, India Hospital N
	Q27	‘The surgeons of course, they are not so much interested in antimicrobials. Internal medicine, of course they are. They are, infection disease specialists are a team in our subspecialty internal medicine, so they will get information from the infectious disease specialists more than other specialties in the hospital.’ Head of Department, Norway Hospital C
	Q28	‘And if you compare Norway to the UK which, I think we are more I guess egalitarian but …. it’s not accepted that someone has his own way of giving antimicrobials, although you are German and, or French and come to work here, you have to adjust, and if you don’t adjust the medical, the chief of the medical doctors would say no, and you have to adjust or I would do it, I don’t have to do that because it’s, the leadership in the medical department is quite strong. if you look at, different surgeons can often do things a little bit different but we work to standardise everything … and all the doctors do everything with the same procedure, and we want that there. Chief surgeon of gastro surgery decides how we do it in this hospital, and it’s all up to four different doctors to treat the patient differently. That, we have some work to do there but when it, in regards antimicrobials, or using a ring, or stuff like that, we do have authority … to change that behaviour. Medical Director, Norway Hospital D
	Q29	‘We’ve got one of our trauma and orthopaedic consultants who actually goes around surgical wards with one of our pharmacists and audits other surgeon specialties and goes and tells them their surgical prophylaxis is too long. And that again…. is just much more powerful than me going with a big report and saying, we snooped behind your back and did this audit and this is…’ Consultant Pharmacist, England Hospital V