Dominique Lescure

Background and aim
The public health problem of antibiotic resistance needs to be addressed to ensure antibiotics remain effective in the future. The primary care setting is an important target area, as most of antibiotics for human use are being prescribed here. The overuse and inappropriate use of antibiotics are both triggers for bacteria to become resistant. The antibiotic prescription volume shows large variation within Europe. The Netherlands is one of the countries with the lowest antibiotic prescription rates. Still, variation between practices and the inappropriate prescription of antibiotics is substantial, especially regarding antibiotics for respiratory tract infections.

Over the years, there has been broad attention for finding effective strategies to stimulate more appropriate antibiotic prescribing. Among them there are various interventions that focused on improving the doctor-patient interaction. Multi-faceted interventions that include communication skills training for general practitioners (GPs) are shown to be most effective in reducing antibiotic prescribing. Although these interventions have proven their value, most of them are focused on the general population. Interventions that consider the needs of different population groups are scarce, despite the fact that populations are growing more diverse. Despite the increasing share of immigrants in society, there is only limited knowledge about their perceptions regarding antibiotics.

The appropriateness of antibiotic treatment might be further improved by targeting different population groups, specifically those with an immigrant background. On the one hand, immigrant patients might hold other cultural beliefs about healthcare or may experience a language barrier, which complicates interacting with the GP and following up medical advice. On the other hand, GPs may experience pressure to prescribe antibiotics for persons with an immigrant background because of this language barrier, or because GPs may lack culturally sensitive communication skills.

The aim of this thesis is to gain a better understanding of the (in)appropriate use of antibiotics by different population groups and the inappropriate prescribing of antibiotics by GPs, with a specific focus on prescribing antibiotics for immigrant patients. Furthermore, this thesis intents to evaluate a communication training for GPs that we developed and implemented based on the found insights into existing attitudes and practices. The intervention aimed to reduce the inappropriate prescribing of antibiotics, with the implicit assumption that it will help control antibiotic resistance.

The central research questions of this thesis are:
1. What are the determinants for self-medication with antibiotics?
2. What are the perceptions, attitudes and experiences of GPs and pharmacists regarding providing antibiotics to immigrant patients and their interaction with them?
3. What are perceptions, attitudes and practices of immigrant and native Dutch individuals concerning antibiotic use and the related GP-patient communication?
4. Which communication intervention package can be developed for GPs aiming at reducing inappropriate antibiotic prescription?
5. Is a communication intervention for GPs and their immigrant patients effective in reducing inappropriate antibiotic prescription?

Main findings

Determinants for self-medication with antibiotics
In chapter 2 we aimed to identify determinants of self-medication with antibiotics via a systematic literature review. There are various forms of self-medication, for instance the use of leftover antibiotics from previous prescribed courses or buying antibiotics at the pharmacy without a medical prescription. Because self-medication is often inappropriately due to the absence of medical guidance, it contributes to antibiotic resistance. We performed a comprehensive