title: Identification of cultural determinants of antibiotic use cited in primary care in Europe: a mixed research synthesis study of integrated design "Culture is all around us".
abstract: BACKGROUND
  Inappropriate antibiotic prescribing, particularly for respiratory tract infections (RTI) in ambulatory care, has become a worldwide public health threat due to resulting antibiotic resistance. In spite of various interventions and campaigns, wide variations in antibiotic use persist between European countries. Cultural determinants are often referred to as a potential cause, but are rarely defined. To our knowledge, so far no systematic literature review has focused on cultural determinants of antibiotic use. The aim of this study was to identify cultural determinants, on a country-specific level in ambulatory care in Europe, and to describe the influence of culture on antibiotic use, using a framework of cultural dimensions.
  
  
  METHODS
  A computer-based systematic literature review was conducted by two research teams, in France and in Norway. Eligible publications included studies exploring antibiotic use in primary care in at least two European countries based on primary study results, featuring a description of cultural determinants, and published between 1997 and 2015. Quality assessment was conducted independently by two researchers, one in each team, using appropriate checklists according to study design. Each included paper was characterized according to method, countries involved, sampling and main results, and cultural determinants mentioned in each selected paper were extracted, described and categorized. Finally, the influence of Hofstede's cultural dimensions associated with antibiotic consumption within a primary care setting was described.
  
  
  RESULTS
  Among 24 eligible papers, 11 were rejected according to exclusion criteria. Overall, 13 papers meeting the quality assessment criteria were included, of which 11 used quantitative methods and two qualitative or mixed methods. The study participants were patients (nine studies) and general practitioners (two studies). This literature review identified various cultural determinants either patient-related (illness perception/behaviour, health-seeking behaviour, previous experience, antibiotic awareness, drug perception, diagnosis labelling, work ethos, perception of practitioner) or practitioner-related (RTI management, initial training, antibiotic awareness, legal issues, practice context) or both (antibiotic awareness).
  
  
  CONCLUSIONS
  Cultural factors should be considered as exerting an ubiquitous influence on all the consecutive stages of the disease process and seem closely linked to education. Interactions between determinant categories, cultural dimensions and antibiotic use in primary care are multiple, complex and require further investigation within overlapping disciplines. The context of European projects seems particularly relevant.
authors.affiliation: Department of Public Health, Archet 1 hospital, 1st level, Nice University Hospital, 151, rte St Antoine de Ginestière, CS 23079, 06202, Nice Cedex 3, France. touboul.p@chu-nice.fr.|Department of teaching and research in General Practice, Medical School, University of Nice - Sophia Antipolis, 28, avenue de Valombrose, 06107, Nice, France. touboul.p@chu-nice.fr.
authors.forename: Pia
authors.initials: P
authors.lastname: Touboul-Lundgren
authors.affiliation: Department of General Practice/Family Medicine, University of Oslo, Oslo, Norway. siri.jensen@medisin.uio.no.|Antibiotic Centre for Primary Care, Institute of Health and Society, University of Oslo, Oslo, Norway. siri.jensen@medisin.uio.no.
authors.forename: Siri
authors.initials: S
authors.lastname: Jensen
authors.affiliation: Department of Public Health, Archet 1 hospital, 1st level, Nice University Hospital, 151, rte St Antoine de Ginestière, CS 23079, 06202, Nice Cedex 3, France. johanndrai@hotmail.com.|Department of teaching and research in General Practice, Medical School, University of Nice - Sophia Antipolis, 28, avenue de Valombrose, 06107, Nice, France. johanndrai@hotmail.com.
authors.forename: Johann
authors.initials: J
authors.lastname: Drai
authors.affiliation: Department of General Practice/Family Medicine, University of Oslo, Oslo, Norway. morten.lindbak@medisin.uio.no.|Antibiotic Centre for Primary Care, Institute of Health and Society, University of Oslo, Oslo, Norway. morten.lindbak@medisin.uio.no.
authors.forename: Morten
authors.initials: M
authors.lastname: Lindbæk
mesh_terms: D000553:Ambulatory Care; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D003469:Culture; D004352:Drug Resistance, Microbial; D005060:Europe; D005260:Female; D006801:Humans; D008297:Male; D011320:Primary Health Care; D012141:Respiratory Tract Infections / Q000188:drug therapy*
chemical_list: D000900:Anti-Bacterial Agents