Autonomy, power dynamics and antibiotic use in primary healthcare: A qualitative study

Laura Medina-Perucha, Ana García-Sangenís, Ana Moragas, Pablo Gálvez-Hernández, Josep María Cots, Anna Lanau-Roig, Alícia Borràs, Isabel Amo, Ramon Monfà, Carl Llor, Anna Berenguera, Laura Medina-Perucha, Ana García-Sangenís, Ana Moragas, Pablo Gálvez-Hernández, Josep María Cots, Anna Lanau-Roig, Alícia Borràs, Isabel Amo, Ramon Monfà, Carl Llor, Anna Berenguera

Abstract

Antibiotic resistance is a global health concern. Although numerous strategies have tried to reduce inadequate antibiotic prescribing, antibiotics are still prescribed in 60% of acute lower respiratory tract infections (ALRTIs) cases in Catalonia (Spain). This study aims to explore service users' experiences of ALRTIs, the quality and access to healthcare services, and health education. Selective purposive sampling was carried out, based on a prior definition of participant characteristics. These were sex, age, ethnicity, date of the last ALRTI, number of ALRTIs in the last year, and treatments received. Participants with a previous diagnosis of ALRTIs were recruited from three primary health care centres in Barcelona and one in Tarragona. Twenty-nine interviews were conducted between April and June 2019. A content thematic analysis was performed. Three themes were identified: 1) risk perceptions and help-seeking; 2) treatment preferences and antibiotic use; and 3) relationship dynamics and communication with healthcare professionals. Accounts of service users' sense of autonomy towards their health and power dynamics within the healthcare system were apparent. Supporting service users to become reliable, subjective and agentic experts of their health and bodies could help them to voice their healthcare agendas. Power structures embedded within healthcare, political and economic institutions should be challenged so that healthcare services can be co-developed (with service users) and based on service users' autonomy and horizontal relationships. Special consideration should be paid to the intersection of social vulnerabilities. A concordance approach to prescribing could be key to improve the responsible use of antibiotics and to contribute to the prevention of AMR in primary healthcare. The marketisation of health, and the increased demands of private healthcare in Spain due to the financial pressures on public healthcare as a consequence of the financial crisis of 2008 and the COVID-19 pandemic, are a risk for promoting adequate antibiotic prescribing and use. Trial registration The ISAAC-CAT study has been registered in the NCT registry, ID: NCT03931577.

Conflict of interest statement

The authors have declared that no competing interests exist.

References

    1. O’Neill J. Antimicrobial resistance: tackling a crisis for the health and wealth of nations. Rev Antimicrob Resist. 2014.
    1. World Health Organization. Global action plan on antimicrobial resistance. Geneva; 2015.
    1. Levy SB, Marshall B. Antibacterial resistance worldwide: causes, challenges and responses. Nat Med [Internet]. 2004;10(12):S122–9. Available from: 10.1038/nm1145
    1. Founou RC, Founou LL, Essack SY. Clinical and economic impact of antibiotic resistance in developing countries: A systematic review and meta-analysis. PLoS One. 2017;12(12):e0189621 10.1371/journal.pone.0189621
    1. United Nations. Transforming our world: The 2030 agenda for sustainable development. Geneva; 2015.
    1. Gulliford MC, Dregan A, Moore M V, Ashworth M, Staa T van, McCann G, et al. Continued high rates of antibiotic prescribing to adults with respiratory tract infection: survey of 568 UK general practices. BMJ Open. 2014. October;4(10):e006245 10.1136/bmjopen-2014-006245
    1. Costelloe C, Metcalfe C, Lovering A, Mant D, Hay AD. Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis. BMJ [Internet]. 2010. May 18;340:c2096 Available from: 10.1136/bmj.c2096
    1. Meeker D, Linder JA, Fox CR, Friedberg MW, Persell SD, Goldstein NJ, et al. Effect of Behavioral Interventions on Inappropriate Antibiotic Prescribing Among Primary Care Practices: A Randomized Clinical Trial. JAMA [Internet]. 2016. February 9;315(6):562–70. Available from: 10.1001/jama.2016.0275
    1. Kimura Y, Fukuda H, Hayakawa K, Ide S, Ota M, Saito S, et al. Longitudinal trends of and factors associated with inappropriate antibiotic prescribing for non-bacterial acute respiratory tract infection in Japan: A retrospective claims database study, 2012–2017. PLoS One. 2019;14(10):e0223835 10.1371/journal.pone.0223835
    1. Goossens H, Ferech M, Vander Stichele R, Elseviers M. Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. Lancet [Internet]. 2005;365(9459):579–87. Available from: 10.1016/S0140-6736(05)17907-0
    1. Fleming-Dutra KE, Hersh AL, Shapiro DJ, Bartoces M, Enns EA, File TMJ, et al. Prevalence of Inappropriate Antibiotic Prescriptions Among US Ambulatory Care Visits, 2010–2011. JAMA. 2016. May;315(17):1864–73. 10.1001/jama.2016.4151
    1. Smith SM, Fahey T, Smucny J, Becker LA. Antibiotics for acute bronchitis. Cochrane database Syst Rev. 2014. March;(3):CD000245 10.1002/14651858.CD000245.pub3
    1. Smith SM, Fahey T, Smucny J, Becker LA. Antibiotics for acute bronchitis. Cochrane database Syst Rev. 2017. June;6:CD000245 10.1002/14651858.CD000245.pub4
    1. Llor C, Cots JM, Hernandez S, Ortega J, Arranz J, Monedero MJ, et al. Effectiveness of two types of intervention on antibiotic prescribing in respiratory tract infections in Primary Care in Spain. Happy Audit Study. Aten primaria. 2014. November;46(9):492–500. 10.1016/j.aprim.2014.02.006
    1. Agencia Española de Medicamentos y Productos Sanitarios. Plan Nacional Resistencia Antibióticos. Consumos Antibióticos Atención Primaria [Internet]. 2018. Available from:
    1. ECDC. Summary of the latest data on antibiotic consumption in the European Union [Internet]. 2018. Available from:
    1. European Comission. Special Eurobarometer 445, Antimicrobial Resistance [Internet]. 2016. Available from:
    1. Arnold SR, Straus SE. Interventions to improve antibiotic prescribing practices in ambulatory care. Cochrane database Syst Rev. 2005. October;(4):CD003539 10.1002/14651858.CD003539.pub2
    1. van der Velden AW, Pijpers EJ, Kuyvenhoven MM, Tonkin-Crine SKG, Little P, Verheij TJM. Effectiveness of physician-targeted interventions to improve antibiotic use for respiratory tract infections. Br J Gen Pract. 2012. December;62(605):e801–7. 10.3399/bjgp12X659268
    1. Tonkin-Crine SK, Tan PS, van Hecke O, Wang K, Roberts NW, McCullough A, et al. Clinician-targeted interventions to influence antibiotic prescribing behaviour for acute respiratory infections in primary care: an overview of systematic reviews. Cochrane database Syst Rev. 2017. September;9:CD012252 10.1002/14651858.CD012252.pub2
    1. Morgan DJ, Okeke IN, Laxminarayan R, Perencevich EN, Weisenberg S. Non-prescription antimicrobial use worldwide: a systematic review. Lancet Infect Dis. 2011. September;11(9):692–701. 10.1016/S1473-3099(11)70054-8
    1. Servia-Dopazo M, Figueiras A. Determinants of antibiotic dispensing without prescription: a systematic review. J Antimicrob Chemother. 2018. December;73(12):3244–53. 10.1093/jac/dky319
    1. McCullough AR, Parekh S, Rathbone J, Del Mar CB, Hoffmann TC. A systematic review of the public’s knowledge and beliefs about antibiotic resistance. J Antimicrob Chemother. 2016. January;71(1):27–33. 10.1093/jac/dkv310
    1. McCullough AR, Rathbone J, Parekh S, Hoffmann TC, Del Mar CB. Not in my backyard: a systematic review of clinicians’ knowledge and beliefs about antibiotic resistance. J Antimicrob Chemother. 2015. September;70(9):2465–73. 10.1093/jac/dkv164
    1. Gonzalez-Gonzalez C, Lopez-Vazquez P, Vazquez-Lago JM, Pineiro-Lamas M, Herdeiro MT, Arzamendi PC, et al. Effect of Physicians’ Attitudes and Knowledge on the Quality of Antibiotic Prescription: A Cohort Study. PLoS One. 2015;10(10):e0141820 10.1371/journal.pone.0141820
    1. Strumann C, Steinhaeuser J, Emcke T, Sönnichsen A, Goetz K. Communication training and the prescribing pattern of antibiotic prescription in primary health care. PLoS One [Internet]. 2020. May 19;15(5):e0233345 Available from: 10.1371/journal.pone.0233345
    1. Van der Velden A, Duerden MG, Bell J, Oxford JS, Altiner A, Kozlov R, et al. Prescriber and Patient Responsibilities in Treatment of Acute Respiratory Tract Infections—Essential for Conservation of Antibiotics. Vol. 2, Antibiotics. 2013.
    1. Altiner A, Brockmann S, Sielk M, Wilm S, Wegscheider K, Abholz H-H. Reducing antibiotic prescriptions for acute cough by motivating GPs to change their attitudes to communication and empowering patients: a cluster-randomized intervention study. J Antimicrob Chemother. 2007. September;60(3):638–44. 10.1093/jac/dkm254
    1. Cals JWL, Butler CC, Hopstaken RM, Hood K, Dinant G-J. Effect of point of care testing for C reactive protein and training in communication skills on antibiotic use in lower respiratory tract infections: cluster randomised trial. BMJ. 2009. May;338:b1374 10.1136/bmj.b1374
    1. Coxeter P, Del Mar CB, McGregor L, Beller EM, Hoffmann TC. Interventions to facilitate shared decision making to address antibiotic use for acute respiratory infections in primary care. Cochrane database Syst Rev. 2015. November;(11):CD010907 10.1002/14651858.CD010907.pub2
    1. Hoffmann TC, Légaré F, Simmons MB, McNamara K, McCaffery K, Trevena LJ, et al. Shared decision making: what do clinicians need to know and why should they bother? Med J Aust. 2014. July;201(1):35–9. 10.5694/mja14.00002
    1. McDermott L, Leydon GM, Halls A, Kelly J, Nagle A, White J, et al. Qualitative interview study of antibiotics and self-management strategies for respiratory infections in primary care. BMJ Open. 2017. November;7(11):e016903 10.1136/bmjopen-2017-016903
    1. Saliba-Gustafsson EA, Röing M, Borg MA, Rosales-Klintz S, Lundborg CS. General practitioners’ perceptions of delayed antibiotic prescription for respiratory tract infections: A phenomenographic study. PLoS One. 2019;14(11):e0225506 10.1371/journal.pone.0225506
    1. Sargent L, McCullough A, Del Mar C, Lowe J. Using theory to explore facilitators and barriers to delayed prescribing in Australia: a qualitative study using the Theoretical Domains Framework and the Behaviour Change Wheel. BMC Fam Pract. 2017. February;18(1):20 10.1186/s12875-017-0589-1
    1. Høye S, Frich J, Lindbœk M. Delayed prescribing for upper respiratory tract infections: a qualitative study of GPs’ views and experiences. Br J Gen Pract J R Coll Gen Pract. 2010. December;60(581):907–12. 10.3399/bjgp10X544087
    1. Ryves R, Eyles C, Moore M, McDermott L, Little P, Leydon GM. Understanding the delayed prescribing of antibiotics for respiratory tract infection in primary care: a qualitative analysis. BMJ Open. 2016. November;6(11):e011882 10.1136/bmjopen-2016-011882
    1. Dallas A, Davey A, Mulquiney K, Davis J, Glasziou P, Van Driel M, et al. Delayed prescribing of antibiotics for acute respiratory infections by GP registrars: a qualitative study. Fam Pract. 2020. July;37(3):406–11. 10.1093/fampra/cmz079
    1. Tillekeratne LG, Bodinayake CK, Dabrera T, Nagahawatte A, Arachchi WK, Sooriyaarachchi A, et al. Antibiotic overuse for acute respiratory tract infections in Sri Lanka: a qualitative study of outpatients and their physicians. BMC Fam Pract. 2017. March;18(1):37 10.1186/s12875-017-0619-z
    1. Nair M, Tripathi S, Mazumdar S, Mahajan R, Harshana A, Pereira A, et al. “Without antibiotics, I cannot treat”: A qualitative study of antibiotic use in Paschim Bardhaman district of West Bengal, India. PLoS One. 2019;14(6):e0219002 10.1371/journal.pone.0219002
    1. Broom J, Broom A, Kirby E, Gibson AF, Post JJ. How do hospital respiratory clinicians perceive antimicrobial stewardship (AMS)? A qualitative study highlighting barriers to AMS in respiratory medicine. J Hosp Infect. 2017. August;96(4):316–22. 10.1016/j.jhin.2017.05.001
    1. Yin J, Dyar OJ, Yang P, Yang D, Marrone G, Sun M, et al. Pattern of antibiotic prescribing and factors associated with it in eight village clinics in rural Shandong Province, China: a descriptive study. Trans R Soc Trop Med Hyg. 2019. November;113(11):714–21. 10.1093/trstmh/trz058
    1. Chan YY, Bin Ibrahim MA, Wong CM, Ooi CK, Chow A. Determinants of antibiotic prescribing for upper respiratory tract infections in an emergency department with good primary care access: a qualitative analysis. Epidemiol Infect. 2019. January;147:e111 10.1017/S095026881800331X
    1. Fletcher-Lartey S, Yee M, Gaarslev C, Khan R. Why do general practitioners prescribe antibiotics for upper respiratory tract infections to meet patient expectations: a mixed methods study. BMJ Open. 2016. October;6(10):e012244 10.1136/bmjopen-2016-012244
    1. Strandberg EL, Brorsson A, André M, Gröndal H, Mölstad S, Hedin K. Interacting factors associated with Low antibiotic prescribing for respiratory tract infections in primary health care—a mixed methods study in Sweden. BMC Fam Pract. 2016. July;17:78 10.1186/s12875-016-0494-z
    1. Kohut MR, Keller SC, Linder JA, Tamma PD, Cosgrove SE, Speck K, et al. The inconvincible patient: how clinicians perceive demand for antibiotics in the outpatient setting. Fam Pract. 2020. March;37(2):276–82. 10.1093/fampra/cmz066
    1. Hruza HR, Velasquez T, Madaras-Kelly KJ, Fleming-Dutra KE, Samore MH, Butler JM. Evaluation of clinicians’ knowledge, attitudes, and planned behaviors related to an intervention to improve acute respiratory infection management. Infect Control Hosp Epidemiol. 2020. June;41(6):672–9. 10.1017/ice.2020.42
    1. Bordado Sköld M, Aabenhus R, Guassora AD, Mäkelä M. Antibiotic treatment failure when consulting patients with respiratory tract infections in general practice. A qualitative study to explore Danish general practitioners’ perspectives. Eur J Gen Pract. 2017. December;23(1):120–7. 10.1080/13814788.2017.1305105
    1. Kaae S, Malaj A, Hoxha I. Antibiotic knowledge, attitudes and behaviours of Albanian health care professionals and patients—a qualitative interview study. J Pharm policy Pract. 2017;10:13 10.1186/s40545-017-0102-1
    1. Hardy V, Thompson M, Keppel GA, Alto W, Dirac MA, Neher J, et al. Qualitative study of primary care clinicians’ views on point-of-care testing for C-reactive protein for acute respiratory tract infections in family medicine. BMJ Open. 2017. January;7(1):e012503 10.1136/bmjopen-2016-012503
    1. Brookes-Howell L, Hood K, Cooper L, Little P, Verheij T, Coenen S, et al. Understanding variation in primary medical care: a nine-country qualitative study of clinicians’ accounts of the non-clinical factors that shape antibiotic prescribing decisions for lower respiratory tract infection. BMJ Open. 2012;2(4). 10.1136/bmjopen-2011-000796
    1. Altiner A, Knauf A, Moebes J, Sielk M, Wilm S. Acute cough: a qualitative analysis of how GPs manage the consultation when patients explicitly or implicitly expect antibiotic prescriptions. Fam Pract [Internet]. 2004. October 1;21(5):500–6. Available from: 10.1093/fampra/cmh505
    1. Patel A, Pfoh ER, Misra Hebert AD, Chaitoff A, Shapiro A, Gupta N, et al. Attitudes of High Versus Low Antibiotic Prescribers in the Management of Upper Respiratory Tract Infections: a Mixed Methods Study. J Gen Intern Med. 2020 Apr;35(4):1182–8. 10.1007/s11606-019-05433-5
    1. Lum EPM, Page K, Whitty JA, Doust J, Graves N. Antibiotic prescribing in primary healthcare: Dominant factors and trade-offs in decision-making. Infect Dis Heal [Internet]. 2018;23(2):74–86. Available from:
    1. O’Doherty J, Leader LFW, O’Regan A, Dunne C, Puthoopparambil SJ, O’Connor R. Over prescribing of antibiotics for acute respiratory tract infections; a qualitative study to explore Irish general practitioners’ perspectives. BMC Fam Pract. 2019. February;20(1):27 10.1186/s12875-019-0917-8
    1. Lindenmeyer A, Redwood S, Griffith L, Ahmed S, Phillimore J. Recent migrants’ perspectives on antibiotic use and prescribing in primary care: a qualitative study. Br J Gen Pract J R Coll Gen Pract. 2016. November;66(652):e802–9. 10.3399/bjgp16X686809
    1. Barker AK, Brown K, Ahsan M, Sengupta S, Safdar N. Social determinants of antibiotic misuse: a qualitative study of community members in Haryana, India. BMC Public Health. 2017. April;17(1):333 10.1186/s12889-017-4261-4
    1. Zanichelli V, Monnier AA, Tebano G, Stanić BM, Gyssens IC, Pulcini C, et al. Views and experiences with regard to antibiotic use of hospitalized patients in five European countries: a qualitative descriptive study. Clin Microbiol Infect Off Publ Eur Soc Clin Microbiol Infect Dis. 2019. February;25(2):249.e7–249.e12. 10.1016/j.cmi.2018.04.030
    1. Mortazhejri S, Patey AM, Stacey D, Bhatia RS, Abdulla A, Grimshaw JM. Understanding determinants of patients’ decisions to attend their family physician and to take antibiotics for upper respiratory tract infections: a qualitative descriptive study. BMC Fam Pract. 2020. June;21(1):119 10.1186/s12875-020-01196-9
    1. McNulty CAM, Nichols T, French DP, Joshi P, Butler CC. Expectations for consultations and antibiotics for respiratory tract infection in primary care: the RTI clinical iceberg. Br J Gen Pract J R Coll Gen Pract. 2013. July;63(612):e429–36. 10.3399/bjgp13X669149
    1. Bakhit M, Del Mar C, Gibson E, Hoffmann T. Exploring patients’ understanding of antibiotic resistance and how this may influence attitudes towards antibiotic use for acute respiratory infections: a qualitative study in Australian general practice. BMJ Open [Internet]. 2019. March 1;9(3):e026735 Available from: 10.1136/bmjopen-2018-026735
    1. Yantzi R, van de Walle G, Lin J. ‘The disease isn’t listening to the drug’: The socio-cultural context of antibiotic use for viral respiratory infections in rural Uganda. Glob Public Health [Internet]. 2019. May 4;14(5):750–63. Available from: 10.1080/17441692.2018.1542017
    1. Ruiz R, Moragas A, Trapero-Bertran M, Sisó A, Berenguera A, Oliva G, et al. Effectiveness and cost-effectiveness of Improving clinicians’ diagnostic and communication Skills on Antibiotic prescribing Appropriateness in patients with acute Cough in primary care in CATalonia (the ISAAC-CAT study): study protocol for a cluster rando. Trials [Internet]. 2019;20(1):740 Available from: 10.1186/s13063-019-3727-3
    1. Reeves S, Albert M, Kuper A, Hodges BD. Why use theories in qualitative research? BMJ [Internet]. 2008. August 7;337:a949 Available from: 10.1136/bmj.a949
    1. Berenguera A, Fernández de Sanmamed MJ, Pons M, Pujol E, Rodríguez D, Saura S, et al. To Listen, To Observe and To Understand. Bringing Back Narrative into the Health Sciences. Contributions of Qualitative Research. Barcelona: Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAPJGol); 2017.
    1. Yardley L. Dilemmas in qualitative health research. Psychol Heal. 2000;15(2):215–28.
    1. Yardley L. Demonstrating the validity of qualitative research. J Posit Psychol [Internet]. 2017;12(3):295–6. Available from: 10.1080/17439760.2016.1262624
    1. Foucault M. Discipline and Punish: The birth of the prison. New York: Vintage; 1979.
    1. Foucault M. The Birth of the Clinic. Abingdon: Routledge; 1989.
    1. Valls-Llobet C. Mujeres, salud y poder Madrid: Cátedra (Feminismos); 2009.
    1. Haque OS, Waytz A. Dehumanization in Medicine: Causes, Solutions, and Functions. Perspect Psychol Sci [Internet]. 2012. March 1;7(2):176–86. Available from: 10.1177/1745691611429706
    1. Davis JE, González AM. To Fix or To Heal: Patient Care, Public Health, and the Limits of Biomedicine. New York: New York University Press; 2016.
    1. Pound P, Britten N, Morgan M, Yardley L, Pope C, Daker-White G, et al. Resisting medicines: a synthesis of qualitative studies of medicine taking. Soc Sci Med [Internet]. 2005;61(1):133–55. Available from: 10.1016/j.socscimed.2004.11.063
    1. Pollock K. Concordance in Medical Consultations. Oxford: Radcliffe Publishing; 2005.
    1. Stevenson FA, Cox K, Britten N, Dundar Y. A systematic review of the research on communication between patients and health care professionals about medicines: the consequences for concordance. Heal Expect [Internet]. 2004. September 1;7(3):235–45. Available from: 10.1111/j.1369-7625.2004.00281.x
    1. Guerrier M, Légaré F, Turcotte S, Labrecque M, Rivest L-P. Shared Decision Making Does Not Influence Physicians against Clinical Practice Guidelines. PLoS One [Internet]. 2013. April 24;8(4):e62537 Available from: 10.1371/journal.pone.0062537
    1. Nettleton S. The sociology of health and illness. 3rd ed. Cambridge: Polity; 2013.
    1. Lupton D. Medicine as Culture: Illness, Disease and the Body [Internet]. 3rd ed. London; 2012. Available from:
    1. Stewart M. Patient-centered medicine: Transforming the clinical method London: Radcliffe Publishing; 2014.
    1. Saukko P, Oppenheim B, Cooper M, Rousham E. Gaps in communication between different staff groups and older adult patients foster unnecessary antibiotic prescribing for urinary tract infections in hospitals: a qualitative translation approach. Antimicrob Resist Infect Control. 2019. December 1;8 10.1186/s13756-019-0587-2
    1. Légaré F, Guerrier M, Nadeau C, Rhéaume C, Turcotte S, Labrecque M. Impact of DECISION + 2 on patient and physician assessment of shared decision making implementation in the context of antibiotics use for acute respiratory infections. Implement Sci [Internet]. 2013;8(1):144 Available from: 10.1186/1748-5908-8-144
    1. Légaré F, Labrecque M, Cauchon M, Castel J, Turcotte S, Grimshaw J. Training family physicians in shared decision-making to reduce the overuse of antibiotics in acute respiratory infections: a cluster randomized trial. C Can Med Assoc J = J l’Association medicale Can. 2012. September;184(13):E726–34. 10.1503/cmaj.120568
    1. Adisso EL, Borde V, Saint-Hilaire M-È, Robitaille H, Archambault P, Blais J, et al. Can patients be trained to expect shared decision making in clinical consultations? Feasibility study of a public library program to raise patient awareness. PLoS One. 2018;13(12):e0208449 10.1371/journal.pone.0208449
    1. van Esch TEM, Brabers AEM, Hek K, van Dijk L, Verheij RA, de Jong JD. Does shared decision-making reduce antibiotic prescribing in primary care? J Antimicrob Chemother. 2018. November;73(11):3199–205. 10.1093/jac/dky321
    1. Callon M. Some Elements of a Sociology of Translation: Domestication of the Scallops and the Fishermen of St Brieuc Bay. Sociol Rev [Internet]. 1984. May 1;32(1_suppl):196–233. Available from: 10.1111/j.1467-954X.1984.tb00113.x
    1. Joseph-Williams N, Edwards A, Elwyn G. Power imbalance prevents shared decision making. BMJ Br Med J [Internet]. 2014. May 14;348:g3178 Available from: 10.1136/bmj.g3178
    1. Barry CA, Bradley CP, Britten N, Stevenson FA, Barber N. Patients' unvoiced agendas in general practice consultations: qualitative study. BMJ [Internet]. 2000. May 6;320(7244):1246 LP– 1250. Available from:
    1. Bergen C, Stivers T. Patient disclosure of medical misdeeds. J Health Soc Behav. 2013. Jun;54(2):221–40. 10.1177/0022146513487379
    1. Koenig CJ. Patient resistance as agency in treatment decisions. Soc Sci Med. 2011. April;72(7):1105–14. 10.1016/j.socscimed.2011.02.010
    1. Shirk JL, Ballard HL, Wilderman CC, Phillips T, Wiggins A, Jordan R, et al. Public Participation in Scientific Research: a Framework for Deliberate Design. Ecol Soc [Internet]. 2012;17(2). Available from:
    1. Jacques-Aviñó C, Pons-Vigués M, Mcghie JE, Rodríguez-Giralt I, Medina-Perucha L, Mahtani-Chugani V, et al. Participación pública en los proyectos de investigación: formas de crear conocimiento colectivo en salud. Gac Sanit [Internet]. 2019; Available from:
    1. European Comission. Options for Strenghtening Responsible Research and Innovation. Brussels; 2013.
    1. Lopez-Valcarcel BG, Barber P. Economic Crisis, Austerity Policies, Health and Fairness: Lessons Learned in Spain. Appl Health Econ Health Policy. 2017. February;15(1):13–21. 10.1007/s40258-016-0263-0
    1. Pollán M, Pérez-Gómez B, Pastor-Barriuso R, Oteo J, Hernán MA, Pérez-Olmeda M, et al. Prevalence of SARS-CoV-2 in Spain (ENE-COVID): a nationwide, population-based seroepidemiological study. Lancet [Internet]. 2020. July 24; Available from: 10.1016/S0140-6736(20)31483-5
    1. Ab Rahman N, Teng CL, Sivasampu S. Antibiotic prescribing in public and private practice: a cross-sectional study in primary care clinics in Malaysia. BMC Infect Dis. 2016. May;16:208 10.1186/s12879-016-1530-2
    1. Mead N, Bower P. Patient-centredness: a conceptual framework and review of the empirical literature. Soc Sci Med. 2000. October;51(7):1087–110. 10.1016/s0277-9536(00)00098-8
    1. Nimmon L, Stenfors-Hayes T. The “Handling” of power in the physician-patient encounter: perceptions from experienced physicians. BMC Med Educ [Internet]. 2016. April 18;16:114 Available from: 10.1186/s12909-016-0634-0
    1. Yates TD, Davis ME, Taylor YJ, Davidson L, Connor CD, Buehler K, et al. Not a magic pill: a qualitative exploration of provider perspectives on antibiotic prescribing in the outpatient setting. BMC Fam Pract. 2018. June;19(1):96 10.1186/s12875-018-0788-4
    1. van der Zande MM, Dembinsky M, Aresi G, van Staa TP. General practitioners’ accounts of negotiating antibiotic prescribing decisions with patients: a qualitative study on what influences antibiotic prescribing in low, medium and high prescribing practices. BMC Fam Pract. 2019. December;20(1):172 10.1186/s12875-019-1065-x

Source: PubMed

Sponsors en medewerkers

Medische omstandigheden

Geneesmiddelinterventies

3
Abonneren