Understanding Antibiotic Prescribing Behaviour in Primary Care: A Qualitative Study

Background: Inappropriate antibiotic use is a major factor behind the development of antimicrobial resistance. Approximately 85% of antibiotics used for human healthcare are prescribed in primary care. Northern Ireland has high (though falling) antibiotic use. Developing interventions to improve this requires a deep understanding of prescribing decisions. This study aims to explore non-clinical factors influencing primary care prescribing.
Method: We undertook a qualitative study, using in-depth semi-structured interviews. Research ethics approval was from Queen’s University Belfast. Ten general practitioners were recruited. Semi-structured telephonic interviews were conducted in May and June 2019, audio-recorded and transcribed. Thematic analysis was performed using the Braun and Clarke six-phase framework: Transcripts were coded by two researchers, discussed and harmonised, and grouped into themes.
Results: Seven themes were identified: Expectations, patient characteristics, communication, risk-weighing, time pressure, GP’s knowledge and experience, and social norms. Major concerns included diagnostic uncertainty, fear of confrontation, practice culture, and overwhelming workload. Participants described how competing factors affect their antibiotic prescribing decisions. They believed that a long-term culture of past inappropriate antibiotic use reinforced their patients’ expectation of antibiotics. The desire to do the right thing was weighed against time pressures, risks to patients from infection and risks to the prescribers’ reputation if the patient became more unwell or made a complaint.
Conclusion: Our results illustrate the social, psychological and practical (non-clinical) factors which combine to influence prescribing decisions. These results can help guide the design of behavioural interventions to support prescribers and policymakers to improve antimicrobial stewardship.