Table 2 Intervention package and, where relevant, equivalent control-arm processes

Provider side

1. Improved antibiotic stewardship programme:

(a) Each township hospital will establish an antibiotic stewardship working team including the township hospital director and a senior physician. The team will decide local antibiotic policies

(b) The antibiotic stewardship team will hold peer-review meetings on antibiotic use monthly throughout the intervention period and embedded within the routine meetings of family physicians. Before each peer-review meeting, the antibiotic stewardship team will hold an internal meeting to prepare prescription reviews. The results will be sent to individual family physicians through WeChat. Each physician will see their performance of appropriate antibiotic prescribing against the hospital average

(c) The antibiotic stewardship team will organise monthly peer-review meetings in township hospitals to ensure: (1) clear targets are set for appropriate use, (2) specific feedback is provided to high prescribers on improvement, (3) adjusting assessments for individual physicians based on their performance and (4) recording monthly meeting memos

(d) The research team will make monthly supervisory visits to intervention township hospitals. The supervisory visits will ensure: (1) adherence to the interventional activities, (2) feedback and an opportunity to answer questions, (3) meeting with the antibiotic stewardship team to strengthen leadership and their commitment to reduce antibiotic prescriptions

2. Operational guidelines to reduce antibiotic prescribing for ARIs will be used. The guidelines will include patient symptom-based diagnostic algorithms, when to/ not to use antibiotics, and when narrow-spectrum antibiotics are preferred. Based on Chinese guidelines, chest x-ray examinations will be recommended when symptoms indicate pneumonia but clinical signs are not severe, or if a patient makes a second visit with signs indicative of pneumonia. Key health education messages during consultations with patients are also included

(a) Every family physician in the township hospitals will receive an operational guideline both in printed and app-based form

(b) Village doctors will receive a brief operational guide regarding appropriate use of antibiotics and referral

3. Systematic training including a half-day training workshop run by a county-level hospital senior physician and the research team will be given to family physicians and village doctors. This will involve:

(a) Lectures, case discussions, role plays and Q&As on appropriate antibiotic prescribing practices for RTIs based on operational guidelines. Every family physician in the township hospitals will receive a training booklet both in printed and WeChat-app form

(b) Using the WeChat app to monitor antibiotic use based on monthly reports from the EMR system to facilitate physicians’ discussions

(c) Communication skills training when consulting with patients and/or caregivers

4. Improved electronic prescription system in the EMR to help township hospital family physicians make appropriate decisions when treating patients for RTIs, involving:

(a) Embedded modules to encourage appropriate antibiotic prescribing practice, such as pops-up of laboratory test checklists and recommended antibiotics to prescribe when prescribing

(b) An alarm system will be implemented to alert the family physician about any patient who re-visits any hospital within 14 days or who has been admitted within 1 month for a respiratory infection or sepsis after their index visit. In this scenario, chest x-ray and blood profile examinations will be recommended and recorded

1. Currently most township hospitals have an existing antibiotic stewardship programme. However, the programmes are often not functioning because of specific targets and activities are planned/implemented. Township family physicians do already hold monthly administrative meetings, but no time is spent on antibiotic prescribing peer-review discussions

2. Township hospital family physicians will prescribe antibiotics according to existing national guide on use of antibiotics which are not specifically designed for primary care facilities, and rarely used. Most physicians prescribe based on their group practice and existing knowledge/practices. Any messages given by control-arm family physicians will be at their own discretion based on their existing practice and training

3. Township hospital family physicians receive relevant medical training before they obtain their qualifications, but only a few of them have opportunities to receive continuing training afterwards and these trainings are usually not specifically for respiratory infections or antibiotics use. We will not provide any training to control-arm family physicians

4. Township hospitals already have a similar electronic prescription system in the EMR, but there is no clinical decision module, alarm system or pop-ups for recommended and non-recommended antibiotics. We will not make this available for control-arm hospitals

Consumer side (patients/caregivers)

1. Printed educational material and WeChat-app versions describing appropriate antibiotic use for respiratory infections will be available during the intervention period. These educational materials along with education videos will be accessible for the public in the township hospital public areas

2. Patients will be invited to scan a QR code to link their WeChat account to the township hospital public WeChat account for receiving health education materials, making queries and comments, and viewing suggestions about common queries

1. There are and will be no health education materials on appropriate antibiotic use available in control-arm hospitals

2. Currently, township hospital do not have WeChat public accounts for patients, so we will not implement them in control-arm hospitals