title: Interacting factors associated with Low antibiotic prescribing for respiratory tract infections in primary health care - a mixed methods study in Sweden.
abstract: Prescribing of antibiotics for common infections varies widely, and there is no medical explanation. Systematic reviews have highlighted factors that may influence antibiotic prescribing and that this is a complex process. It is unclear how factors interact and how the primary care organization affects diagnostic procedures and antibiotic prescribing. Therefore, we sought to explore and understand interactions between factors influencing antibiotic prescribing for respiratory tract infections in primary care.
  
  
  
  Our mixed methods design was guided by the Triangulation Design Model according to Creswell. Quantitative and qualitative data were collected in parallel. Quantitative data were collected by prescription statistics, questionnaires to patients, and general practitioners' audit registrations. Qualitative data were collected through observations and semi-structured interviews.
  
  
  
  From the analysis of the data from the different sources an overall theme emerged: A common practice in the primary health care centre is crucial for low antibiotic prescribing in line with guidelines. Several factors contribute to a common practice, such as promoting management and leadership, internalized guidelines including inter-professional discussions, the general practitioner's diagnostic process, nurse triage, and patient expectation. These factors were closely related and influenced each other. The results showed that knowledge must be internalized and guidelines need to be normative for the group as well as for every individual.
  
  
  
  Low prescribing is associated with adapted and transformed guidelines within all staff, not only general practitioners. Nurses' triage and self-care advice played an important role. Encouragement from the management level stimulated inter-professional discussions about antibiotic prescribing. Informal opinion moulders talking about antibiotic prescribing was supported by the managers. Finally, continuous professional development activities were encouraged for up-to-date knowledge.
authors.affiliation: Department of Clinical Sciences, Malmö, Family Medicine, Lund University, Malmö, Sweden. eva-lena.strandberg@med.lu.se.|Blekinge Centre of Competence, Blekinge County Council, Karlskrona, Sweden. eva-lena.strandberg@med.lu.se.
authors.forename: Eva Lena
authors.initials: EL
authors.lastname: Strandberg
authors.affiliation: Department of Clinical Sciences, Malmö, Family Medicine, Lund University, Malmö, Sweden.|Center for Primary Health Care Research, Malmö, Skåne Region, Sweden.
authors.forename: Annika
authors.initials: A
authors.lastname: Brorsson
authors.affiliation: Department of Medicine and Health Sciences, Family Medicine, Linköping University, Linköping, Sweden.|Department of Public Health and Caring Sciences - Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden.
authors.forename: Malin
authors.initials: M
authors.lastname: André
authors.affiliation: Department of Sociology Uppsala, Uppsala University, Uppsala, Sweden.
authors.forename: Hedvig
authors.initials: H
authors.lastname: Gröndal
authors.affiliation: Department of Clinical Sciences, Malmö, Family Medicine, Lund University, Malmö, Sweden.
authors.forename: Sigvard
authors.initials: S
authors.lastname: Mölstad
authors.affiliation: Department of Clinical Sciences, Malmö, Family Medicine, Lund University, Malmö, Sweden.|Department of Research and Development, Region Kronoberg, Växjö, Sweden.
authors.forename: Katarina
authors.initials: K
authors.lastname: Hedin
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D011307:Drug Prescriptions / Q000706:statistics & numerical data*; D005260:Female; D058006:General Practice / Q000379:methods; D019538:Health Care Surveys; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007400:Interprofessional Relations; D007407:Interviews as Topic; D007857:Leadership; D008297:Male; D024802:Nurse's Role; D057240:Patient Preference; D017410:Practice Guidelines as Topic; D011320:Primary Health Care / Q000458:organization & administration* / Q000706:statistics & numerical data*; D012141:Respiratory Tract Infections / Q000188:drug therapy*; D012648:Self Care; D013548:Sweden; D014218:Triage / Q000458:organization & administration
chemical_list: D000900:Anti-Bacterial Agents
keywords: Antibiotic prescribing; Guidelines; Implementation; Mixed methods design; Primary care