Factors, attitudes and perceptions about antibiotic prescribing: a critical review of qualitative studies.

A Rodrigues1,2, F Roque1,3, A Falcão2,4, A Figueiras5, MT Herdeiro1,6. 1University of Aveiro, Center for Cell Biology(CBC/UA), Portugal, 2University of Coimbra, Faculty of Pharmacy, Portugal, 3Polytechnic Institute of Guarda, Research Unit for Inland Development (UDI/IPG), Portugal, 4University of Coimbra, Center for Neuroscience and Cell Biology (CNC/UC), Portugal, 5University of Santiago de Compostela, Consortium for Biomedical Research in Epidemiology & Public Health (CIBER en Epidemiología y Salud Pública - CIBERESP), Spain, 6University of Porto, Center for Health Technology & Information Systems Research (CINTESIS/FMUP), Portugal, 7Polytechnic Health Institute of the North, Health Technology Research Center (CITS/CESPU), Portugal

Introduction: Rates of antibiotic resistance are growing worldwide. Misuse and overprescribing of antibiotics are considered the most important cause in the development of this important public health problem. Thus, it is important to identify and explore attitudes of healthcare providers related to this global concern.

Aim: To carry out a critical review of qualitative studies about factors, attitudes and behaviors related to antibiotic prescribing, and identify determinants of prescribing habits.

Methods: Using the scientific MEDLINE database (PubMed), research team selected qualitative studies published between January 1987 and December 2011, about attitudes, knowledge and perceptions of physicians related to antibiotics use.

The following search terms and their equivalents were used: (attitude* OR knowle* OR percept*) AND (physician* OR doctor* OR practitioner*) AND (antibiotic OR antimicrobial*).

Data extraction included study population, work place, sample size, pathology, patients, method of data collection and method of analysis.

Results: Thirty-three studies were included in this review. Twenty studies only included physicians, five studies included also patients and/or their caregivers, three included physicians and nurses and, in one paper study included pharmacists and physicians. There was one study that included physicians, nurses and patients, and another paper with physicians, nurses and pharmacists. Another selected papers evaluated physicians, patients, pharmacists practice and others key informants, and one study included physicians, pharmacists and veterinarians.

Pathologies targeted in ten studies were respiratory tract infections. In the other studies pathologies targeted were: urinary tract infection (two), spinal cord injury/disorder (two) and infectious diseases (two), surgical site infections (one) and diarrhea (one). In one paper, the authors use patients with respiratory tract infection and diarrhea simultaneously. The remaining fourteen articles (47%) did not identify the pathology.

Different methods of data collection were used in the various studies. Mostly used semi-structured and/or “think-aloud” interviews (sixteen), self-administered questionnaires (ten) or focus group discussions (five). Recorded consultations was used in one paper and in other was used this methodology followed by open interviews.

Factors that may influence antibiotic prescribing, identified in studies reviewed, could be grouped in two categories: intrinsic factors (such as socio-demographics, attitudes and knowledge of physicians) and external factors (namely patient-related factors, health care system customs or the influence of pharmaceutical companies). In our review, it was also possible identify factors that influence the success of strategies designed to improve antibiotic prescribing such as some barriers.

Conclusion: Qualitative methodology is a very useful tool to explore all the factors that influence the antibiotic prescribing. It is very important to identify and measure the attitudes and factors related to antibiotic prescribing before design an intervention to improve prescription habits. Interventions must be tailored to barriers identified.

Aknowlegement

This work was supported by Foundation for Science and Technology (Fundação para a Ciência e Tecnologia - FCT), grants [PTDC/SAU-ESA/105530/2008] from the Portuguese Ministry of Science and Education, and Health Research Fund (Fondo de Investigación Sanitaria) grants [PI081239 and PI09/90609] from the Spanish Ministry of Health.